REBECCA LEACH, RN, BSN, MPH, CIC, has been an infection preventionist since 2010, with a background in nursing and epidemiology. Leach, a member of Infection Control Today®’s Editorial Advisory Board, currently works at a healthcare system in Phoenix, Arizona, that includes 5 hospitals and more than 100 outpatient treatment centers.

Rebecca Leach, MPH, BSN, RN, CIC

The COVID-19 pandemic has contributed to rapid adjustments and innovations in infection prevention and public health practices over the past 2 years. Health care cleaning and disinfection also gained a spotlight as a key piece to the infection prevention program in facilities. While this was not a new concept for infection preventionists and environmental services departments, it brought a public awareness to the various types of disinfectants and how crucial cleaning of surfaces is to decrease risk of disease transmission.

Continuously Active Disinfection (CAD) Chemicals

The first innovation in cleaning and disinfection is continuously active disinfection (CAD) chemicals. Previously, CAD was a focus of materials, not chemicals. Copper- and silver-infused items, such as bedside tables, bed rails, IV poles, linens, and curtains were brought to the market as solutions to contamination of objects and a passive way to break the chain of infection for indirect and direct contact. Ultimately, there were challenges with this type of solution, including the cost of implementation and evidence to support the effectiveness. A 2016 ECRI report found that there was not a statistically significant difference between copper treated rooms and control rooms with no copper fixtures

. Based on the review, the return on investment was not evident for having a room full of copper fixtures—let alone an entire ward.

Newer technology with disinfectants that provide continuous activity is emerging and shows some promise that it may be effective with extended kill times, and potentially decrease risk of organism transmission in the environment. One such product, which is a pre-moistened wipe or spray system, has been shown to actively kill pathogens for up to 24 hours

. More studies need to be completed in real-life situations to determine the effectiveness of such products; however, theoretically they would be a less expensive alternative to metal-infused surfaces. Utilization of CADs in areas where there is high traffic, but not as frequent cleaning, would be ideal. Such areas would be emergency department waiting areas, clinic lobbies, hospital chapels, outer areas of procedural and surgical rooms, and nurse and physician charting areas.

Second, innovations in delivery systems for disinfection products have developed recently. Ultraviolet (UV) technology is not a new concept, having been introduced as a portable system for health care facilities several years ago. However, latest updates to the products available include shorter run times and smaller devices that can accommodate cell phones or stethoscopes. Also, misting devices that efficiently spread disinfectants such as hydrogen peroxide offer a delivery system that is efficient for large spaces. Multiple studies have looked at the use of UV and misting systems, with statistically significant results in reduction of adverse patient outcomes

. Two of the main challenges with these systems are cost and workflow constraints. Foundations with donors’ contributions or grants may help alleviate some of the costs, but infection preventionists need to work with environmental services and facility leadership to develop workflows for the use of these devices in the most efficient and beneficial manner to maintain throughput.

Cleaning and Disinfection of Shared or Reusable Equipment

Finally, cleaning and disinfection of shared or reusable equipment continues to be a challenge for infection preventionists. Accreditation bodies have increased their awareness on this topic, looking at glucometers, stethoscopes, and other equipment and instruments that travel from room to room. Similarly, the updated Association for the Advancement of Medical Instrumentation (AAMI) standard ST91 for flexible endoscopes will transform the way many health care facilities handle the disinfection, sterilization, and storage of their scope

. Sterilization of scopes and the increased use of disposable scopes will be hot topics going forward as infection preventionists partner with endoscopy and sterile processing colleagues.

As health care environmental hygiene continues to evolve, one concept remains consistent: basic practices of cleaning and disinfection by trained and competent staff are a foundation upon which these latest technologies and updates to standards build upon. Without a skilled environment services and sterile processing team, adjuncts to daily cleaning and disinfection will not be effective. As with many infection prevention initiatives, a bundled approach works best to target multiple steps along the chain of infection and improve both human and process factors along the way.

Antimicrobial Copper Surfaces for Reducing Hospital-acquired Infection Risk: Evidence Summary of Selected Outcomes. ECRI Institute. Accessed May 18, 2022. 063 - Antimicrobial Copper Surfaces for Reducing Hospital-acquired Infection Risk (ecri.org).

Heben JN, Fauerback LL. Continuously Active Disinfection: Minimizing the Role of Surface and Equipment Recontamination in the Transmission of Healthcare Pathogens. Accessed May 29, 2022. Sani-24_White-Paper_05190657.pdf.

Peters A, Schmid MN, Parniex P, Lebowitz D, et al. Impact of environmental hygiene interventions on health care-associated infections and patient colonization: a systematic review. Antimicrobial Resistance and Infection Control. February 19, 2022.

Peters J. Updated AAMI ST91 for Endoscope Reprocessing: an HTM Perspective. Accessed May 30, 2022. https://www.aami.org/news/article/updated-aami-st91-2020-for-endoscope-reprocessing-an-htm-perspective.

Articles

Infection preventionists and the equipment and cleansers they use gained a spotlight during the COVID-19 pandemic. These include both established and innovative materials. 


Top 3 Trends in Health Care Cleaning and Disinfection

Infection preventionists are like coaches. We often facilitate the work of a team, assess strengths, teach skills where there are opportunities or gaps, devise strategies for preventing health care­–acquired infections, and look at long-term outcomes and goals. Like coaches, infection preventionists have different styles of collaborating with team members. Each infection preventionist brings personal experience and collaborative style to the role. Also, the culture of an organization can sometimes influence how relationships develop.

As novice infection preventionists, many of us learned how to function as leaders based on whom we trained with. Infection prevention remains a field in which training often is done through hands-on, learn-as-you-go methodology. Additionally, each infection preventionist brings a style of relationship building.

When I was a novice infection preventionist, I had the benefit of being trained by a mentor who exemplified how best to engage with clinical staff at all levels. My mentor had been in her role for many years and had worked for the organization as a staff nurse before moving into infection prevention. She made relationship building a priority for the program and knew how important it was to success. She taught me to listen first, learn what the needs of the clinical staff are, and communicate with empathy and compassion. Those techniques set the baseline for building trust.

Infection preventionists without clinical backgrounds in nursing sometimes have a more difficult path to earning the trust of clinical staff. However, the same skills are effective in beginning the collaboration: Approach clinical staff to learn about their field, treat them as the subject matter experts, and be open to learning from them.

Similarly, clinical staff can have a history of how they have worked with infection preventionists, quality, safety, and similar departments. Depending on the culture of the organization, an unspoken hierarchy can exist within which certain role groups interact. If an organization has this type of hierarchy, it can be challenging for nonclinical or administrative departments, such as infection prevention, to engage clinical staff. Without that engagement, infection prevention initiatives will not succeed.

Some of the interaction between professional groups stems from sociological and psychological dynamics of group relationships. The more infection preventionists can be aware of these dynamics, the better they will be at overcoming potential negative impacts. For example, concepts such as social identity and community of practice have inherent limitations to inclusiveness across professions and even within professional groups of different subspecialties.

 In these instances, the in groups see themselves as superior in knowledge and experience, and may value their own contributions as more important than those of other groups involved in patient care.

 These dynamics have been shown to inhibit quality initiatives and must be addressed early in the planning stages of programs.

There have been efforts to develop methodologies addressing these barriers in group dynamics. Overall, they are best overcome when the approach to solving issues is truly multidisciplinary and based on concepts similar to safety culture, in which there is no hierarchy, and each voice is valued and respected. Infection preventionists can also overcome some of these barriers by continuing to develop interpersonal relationships with clinical staff.

Infection prevention initiatives and programs need collaboration to be effective and to achieve desired outcomes. Health care facilities need to align with clinical staff to make changes, including cultural and behavioral shifts, to spread those desired changes across a multifaceted organization, and to sustain those changes in the face of evolving priorities and growth.

 Infection preventionists can start to address these challenges by identifying key stakeholders, learning what is important to them and what would get their buy-in, making relationship-building efforts a priority, and helping stakeholders take ownership of the changes.

On the positive side, studies have shown that training in teamwork and effective communication in health care settings does translate to improved patient outcomes.

 Additionally, studies have shown that teams with higher levels of trust and quality information exchange do have direct impacts on patients’ satisfaction, pain scores, and length of stay.

 These types of studies can very easily be translated to prevention of health care–associated infections as well.

In particular, transformational leadership styles have been associated with improved quality outcomes for patients.

 Transformational leadership is based on creating relationships and motivating staff through clear communication and shared vision.

 It is imperative that infection preventionists are aware of their leadership styles and attempt to build skills in areas where they may not have experience in order to utilize their position in the facility to act as leaders who will enhance patient outcomes through collaboration.

One positive outcome of the pandemic response has been an improvement in the relationship between infection prevention and clinical staff. Infection preventionists were often at the head of pandemic efforts, working early on to understand the guidance for COVID-19 response; tirelessly providing updates, education, and plans to health care teams; and working with facility administration on incident commands to help establish processes. The infection preventionist had the opportunity to engage with clinical staff at all levels and could provide updates on research, as well as offer an empathetic ear to staff feeling the burden of the unknown. In this role, functioning as part of that clinical team in such an emotionally charged setting, infection preventionists were able to increase trust and establish relationships with clinical staff that will carry forward in all other initiatives.

Building on collaborative relationships that arose from COVID-19 pandemic response, infection preventionists can use their social capital to maintain that momentum. Team building, meeting with unit-based councils, and involving direct care staff from the beginning are all ways to engage and sustain those relationships. Across the country, we have seen an increase in health care–associated infections since the pandemic started. Many years of improvements in quality and patient safety are seemingly reversed. The work of infection preventionists has not decreased since 2020. However, infection preventionists are not alone in their efforts. All of health care is delivered in the context of human relationships. The quality and safety of that care will be improved when those relationships are strong and at the center of an organization’s care delivery model.

Bartunek JM. Intergroup relationships and quality improvement in healthcare. 

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The CAHPS Ambulatory Care Improvement Guide, section 4: ways to approach the quality improvement process. Agency for Healthcare Research and Quality. November 2015. Updated January 2020. Accessed February 13, 2022. https://www.ahrq.gov/cahps/quality-improvement/improvement-guide/4-approach-qi-process/index.html

Rosen MA, DiazGranados D, Dietz AS, et al. Teamwork in healthcare: key discoveries enabling safer, high-quality care. 

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Sfantou DF, Laliotis A, Patelarou AE, Sifaki-Pistolla D, Matalliotakis M, Patelarou E. Importance of leadership style towards quality of care measures in healthcare settings: a systematic review. 

. 2017;5(4):73. doi:10.3390/healthcare5040073


The COVID-19 pandemic strengthened the relationship between infection preventionists and clinicians, but how can both parties ensure continued collaboration?


The IP Relationship With Clinical Staff Is a Critical Partnership

nfection preventionists’ (IPs) roles in emergency response efforts historically have been minimal in health care settings. Typically, the emergency response program completes a risk assessment annually, the Hazard Vulnerability Analysis (HVA).

 In these reviews, all hazard risks are ranked according to likelihood of occurrence, severity of impact, and current capabilities to mitigate risks. Natural disasters, manmade disasters, and pandemics were included in the analyses. I believe most health care facilities would have ranked the likelihood of a pandemic as low, severity of a pandemic as high, and the capability to manage a pandemic would vary greatly from facility to facility.

As the heightened sense of awareness faded after the Ebola response in 2014 and 2015,

 the funding that had been assigned because of that outbreak began to dissipate and other priorities overtook efforts to maintain biopreparedness programs. Maintaining a strong program is expensive for health care facilities, and many of those costs are not redeemable through reimbursement from payers or funding from outside resources.

Along those same concerns, infection prevention staff were pulled into the efforts to reduce health care–acquired infections (HAIs) as those metrics became part of the Hospital Value-Based Purchasing Program and directly affected a facility’s payments from the Centers for Medicaid & Medicare Services (CMS).

The COVID-19 pandemic exposed many areas of challenge to broad pandemic response. The first surges showed how quickly personal protective equipment (PPE) supplies could be decimated and testing capabilities stretched thin beyond use. Later surges tested capacity, staffing, treatment development, and resilience of a health care force. Throughout the pandemic, misinformation and disinformation made coordinated efforts even more challenging and perhaps highlighted an unforeseen challenge to biopreparedness programs.

 How can health care providers be prepared to handle the deluge of opinions from nonexperts on responding to a pandemic response that affect the behaviors and choices of patients and staff alike?

Crisis standards of care were developed by the Centers for Disease Control and Prevention in response to the shortages and challenges facing health care.

 These standards are a framework to help facilities determine thresholds for staging out mitigation factors, such as PPE reuse, staffing models, and capacity limits. Based on these existing guidelines, biopreparedness programs can develop local models of crisis standards that act as triggers for next steps or mitigation factors.

As COVID-19 becomes endemic (as of this writing the threat that the Omicron variant poses is still unknown), now is the time for IPs to harness the current attention to biopreparedness and use the momentum to build the foundations for strong local programs that can be sustained through future waves of competing priorities.

The first step is to gather leadership support to establish a formal program, if one doesn’t exist, or the support to formalize the existing program and expand on its capabilities.

 The next step is to conduct a gap analysis to determine what worked well during the COVID-19 response, what innovations were developed that can become standard practice, and what areas are still opportunities for improvement. Existing gap analyses (eg, the High-Consequence Infectious Disease Preparedness Checklist from the Joint Commission) can be used.

 Part of the gap analysis could include a run-through of a scenario to determine what actions to take if a patient with a high-consequence disease (HCD) comes into the emergency department.

Once the gap analysis is completed, the results will guide the next steps. A formal committee or workgroup of multidisciplinary members who are all stakeholders can be established to take on action items specific to each department. A written plan can be the cornerstone of the committee’s work; however, the document must be flexible and able to be molded to any new HCD encountered. Having a response plan that isn’t focused on 1 specific disease type (ie, Ebola or influenza) allows for adaptation to the unknown—such as COVID-19 was at first—and is essential to be able to quickly respond when all the information isn’t known.7 Additionally, the committee and plan must have a multiyear strategy, as the work cannot be expected to be completed quickly if it is to be built into the foundations of the organization.

Once the plan is established and the committee is meeting routinely, the next step is to train frontline staff and build competency within your workforce. Training is essential to ensure all who may encounter patients with an HCD can quickly recognize potential transmission threats and enact appropriate isolation precautions and escalate quickly.

Education plans need to include training current employees and making biopreparedness training part of orientation and onboarding for new staff. Turnover in hospitals always presents challenges to maintaining efforts, so having a plan to include biopreparedness in the clinical orientation process will be key to making it part of the organization’s culture. Along with training staff, training the infection prevention team to build expertise also will create the strong leadership in the program. Free programs, such as those sponsored by the Center for Domestic Preparedness in Anniston, Alabama, are a great option to immerse IPs in biopreparedness with others who want to learn more.

Another way IPs can help sustain biopreparedness efforts is to be a leader in their organization’s safety culture. IPs can take a leadership role in facility initiatives such as High Reliability, Lean Six Sigma Management, and other concepts and work to integrate biopreparedness into those initiatives.

 Early response and recognition and escalating safety concerns all fit into those safety culture concepts and can help sustain biopreparedness.

Information technology infrastructure needs to be supported in infection prevention programs in general, including biopreparedness. Analytics and surveillance programs that detail threat assessments and detect syndromic patterns and trends across states and regions help predict risk and develop countermeasures. Barriers to communication across international and national surveillance systems need to be addressed to improve the public health response. Collaboration in public health efforts is needed to ensure outbreaks are addressed early and information shared to prevent transmission.

Federal government investment into biopreparedness would increase interest and ability for individuals and organizations to obtain funding in areas of infectious disease that are lacking across the country. The Infectious Diseases Society of America recently released a statement supporting one such effort, the BIO Preparedness Workforce Act.

 This act would increase funding and loan repayment for health care professionals who spend at least half of their time working in biopreparedness roles or providing infectious disease care in underserved communities. The act is still pending review in the US Congress but would be a strong show of support for bolstering the workforce in this up-and-coming field.

Mandating biopreparedness also could be part of CMS conditions of participation or accrediting bodies. As was demonstrated with HAI prevention, once money was tied to outcomes, focus improved and more efforts were made to bolster IPs’ capabilities. The same could potentially be done for biopreparedness, including mandating training, drills, and comprehensive high-consequence disease plans for health care facilities.

IPs can work with their local health departments to build links within acute care, long-term care, community health, and public health surveillance. If your local public health jurisdiction has a biosurveillance program, have your organization join and become part of a larger network feeding information into larger national databases. Then those databases need to be able to generate useful information that can quickly be passed to local providers who are seeing patients in clinics and emergency departments to apply clinical assessments based on known risk factors.

As we continue into the second year of COVID-19 response, IPs are at the front line to ensure biopreparedness programs become a priority for their organizations. Collaboration and advocacy efforts can build the foundation at local levels, but for true sustainability, federal and state regulatory bodies need to take notice and ensure biopreparedness programs become a primary issue going forward.

REBECCA LEACH, MPH, BSN, RN, CIC, has been an infection preventionist since 2010 with a background in nursing and epidemiology. Leach, a member of theInfection Control Today® Editorial Advisory Board, works at a health care system in Phoenix, Arizona, that includes 5 hospitals and more than 100 outpatient treatment centers.

What are the requirements related to the hazard vulnerability analysis (HVA) for organizations and off-site facilities? The Joint Commission. Updated November 16, 2016. Accessed November 30, 2021. https://www.jointcommission.org/standards/standard-faqs/home-care/emergency-management-em/000001196/

Popescu SV. Preparing for special pathogens: an IP perspective. 

https://www.infectioncontroltoday.com/view/preparing-special-pathogens-ip-perspective

The Hospital Value-Based Purchasing Program. CMS. Updated February 18, 2021. Accessed November 30, 2021. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HVBP/Hospital-Value-Based-Purchasing

Leach R. How infection preventionists can battle misinformation. 

®. 2021;25(10):32-33. https://www.infectioncontroltoday.com/view/how-infection-preventionists-can-battle-misinformation

Optimizing supply of PPE and other equipment during shortages. CDC. Updated July 16, 2020. Accessed November 8, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/general-optimization-strategies.html

Franco C, Hansen M. The state of biopreparedness: lessons from leaders, proposals for progress. Conference Reports. Center for Biosecurity of UPMC. Accessed November 30, 2021. 

https://www.centerforhealthsecurity.org/our-work/events-archive/2010_state_of_biopreparedness/conf_report.pdf

Popescu S, Leach R, Robinson K. Establishing a pre-COVID-19 hospital biopreparedness initiative. 

The Joint Commission Guide to Risk Assessment, Joint Commission Resources, 2021. The Joint Commission. August 25, 2021. Accessed November 5, 2021. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/joint-commission-online/aug-25-2021/new-risk-assessment-guide-available-from-jcr/

Atkinson MK, Cagliuso NV Sr, Hick JL, et al. Moving forward from COVID-19: organizational dimensions of effective hospital emergency management. 

 2021;19(5):508-520. doi:10.1089/hs.2021.0115

Center for Domestic Preparedness. Training the best for the worst. FEMA. Accessed November 30, 2021. https://cdp.dhs.gov

High reliability and infection prevention. The Joint Commission. Accessed November 30, 2021. https://www.jointcommission.org/resources/patient-safety-topics/infection-prevention-and-control/high-reliability-and-infection-prevention/

Montella E, Di Cicco MV, Ferraro A, et al. The application of Lean Six Sigma methodology to reduce the risk of healthcare-associated infections in surgery departments. 

2017;23(3):530-539. doi:10.1111/jep.12662

IDSA and HIVMA Support BIO Preparedness Workforce Act. IDSA. News release. October 25, 2021. Accessed November 11, 2021. 

https://www.idsociety.org/news--publications-new/articles/2021/idsa-and-hivma-support-bio-preparedness-workforce-act/

Now is the time for infection preventionists to harness the current attention to biopreparedness and use the momentum to build the foundations for strong local programs that can be sustained through future waves of competing priorities.

Add Biopreparedness to IP Checklist

“Infodemic” combines the words “information” and “epidemic,” typically referring to rapid, far-reaching spread of both accurate and inaccurate information about a topic such as disease or treatment.

 The word first appeared in 2003 but has seen increased use during the COVID-19 pandemic.

The volume of information disseminated since the beginning of the pandemic has been tremendous. In addition to scientific articles and journals based on research about the novel virus and its impact, there have been government statements, health agency advisories, news articles, opinion pieces, and a tidal wave of social media postings and commentary.

Under the infodemic umbrella we have 3 categories: information, misinformation, and disinformation.

 Information is considered accurate at the time based on current knowledge. Because of the ever-changing nature of the pandemic, information was updated regularly; many members of the public and some within the health care industry began to have doubts about how much of it was accurate.

This provides an excellent illustration of how science works. New ideas are tested and more data are gathered to continually improve upon prior hypotheses. Such rapid information updates in a situation involving a novel pathogen are expected, with new knowledge shared as it is uncovered. This does not necessarily mean earlier information was bad. Instead, the best information is shared in real time based on evolving knowledge.

Misinformation is false information without intent of causing harm or challenges to care. It often comes from individuals trying to understand something but not having all the data or not being able to interpret that data correctly.

Disinformation is false information created to cause harm or delay care, for various reasons. It is strategic and intentional and can have severe repercussions.

During this pandemic, we have seen many examples of misinformation and disinformation. The deluge of information makes risk communication and public health messaging more challenging. The social media aspect of this pandemic is unlike anything health responders have experienced previously. The level of expertise for social media postings is not regulated and public figures can exacerbate confusion by promoting misinformation and disinformation.

Early in the COVID-19 response, infection preventionists (IPs) scrambled to get as much credible information as they could to share with hospital leadership, staff, and patients. The days were filled with updates from the CDC, White House staffers, international health organizations, and the news media. Topics covered by IP education included isolation guidance, personal protective equipment information, modes of transmission, viral transmissibility and virulence, risk factors, and risk reduction strategies.

Sifting through the data was a full-time job. Then came the need to organize the information and package it in a shareable manner that could address all concerns and questions. Much time was spent talking through fears, unknowns, what was known, or even best guesses.

A challenge was the frequency with which information was updated. One of the best ways to address that is to let individuals know from the beginning that in pandemic response, we learn as we go and we make decisions based on the best evidence known at the time. We must be open to changing course and being flexible as new data become available.

Infodemiology is an emerging field in public health and has some basic tenets that can be used by IPs in navigating the pandemic. One author has described 4 pillars of infodemic management: (1) facilitating accurate knowledge translation, (2) refining, filtering, and fact-checking, (3) building online health literacy, and (4) monitoring and analyzing data.

 All 4 pillars were utilized by IPs during the initial COVID-19 response and continuously since.

An example of the ripple effects of misinformation involves the antiparasitic drug ivermectin. A preprint journal article indicated a huge reduction in risk of death for patients with COVID-19 who were receiving ivermectin. As other academics and researchers began reviewing the data behind the conclusions, concerns were raised. The content was pulled from the server based on those concerns, but not before it made an impact. It had been viewed more than 150,000 times and cited more than 30, including meta-analyses that concluded ivermectin was effective in treating COVID-19.

Ivermectin was being prescribed as treatment and, for many, as prophylaxis for COVID-19. This example highlights how quickly information spreads digitally, and the desperation for providers to find something that could help patients before vaccines were available. Even now, as the controversy continues, studies have been inconclusive as to the true efficacy of ivermectin, yet there are calls from the public for prescribing it.

At the time of this writing, our department was called by a concerned patient with COVID-19 who wanted a friend to bring ivermectin to the hospital to help treat her. This situation is a great opportunity for providing education and resources, but it also goes against medical advice of providers across the country who are using more proven methods to treat COVID-19.

The World Health Organization has published steps for navigating the infodemic to help the public in using self-assessment tools; however, these can be applied to IPs as they help staff utilize resources.

 The steps are: (1) assess the source, (2) go beyond the headlines, (3) identify the author, (4) check the date, (5) examine supporting evidence, (6) check your biases, and (7) turn to fact-checkers.

The final 2 steps are of particular interest for IPs. We all have unrecognized biases that we need to acknowledge, especially when it comes to infectious disease prevention, because this is our area of expertise. It can be easy to forget that the public and even health care workers are not as familiar with terminology associated with infectious disease and disease transmission. IPs can approach staff with a certain empathy as they try to better understand risks based on all the information.

Fact-checking is a role that IPs have embraced as part of the research-based and data-based foundations of the field. Evidence-based care is the goal, and the same goes for COVID-19 response. IPs know the reliable sources and are familiar with reading scientific studies and being able to translate those findings to staff in an understandable way. Again, IPs should utilize the 4 pillars and incorporate skills many have learned from prior outbreaks and epidemic experiences.

Another way IPs can help fight the infodemic is to gain the trust of the staff they serve. Individuals are more likely to listen and accept information from a source they trust. IPs are collaborative, striving to facilitate and build relationships to promote behavior change and implement interventions to combat health care–associated infections.

IPs can also be creative with messaging. Infographics, using common language like “flatten the curve,” and combining public health messaging with storytelling are all ways IPs can bring innovative methods to education.

 Storytelling is used when reviewing cases of health care–associated infections or other patient safety events. Using stories of patients or from IPs’ personal lives to help others understand the risks and benefits associated with COVID-19 treatments and vaccination can be an effective way of overcoming emotional and fear-based decision-making that we see among the public.

IPs must also craft their messages to ensure the audience is appropriate. Typically, those with set beliefs about vaccination or the existence of COVID-19 are not easily swayed.

 Instead, the focus should be on those displaying hesitancy; those questioning but who have not fully committed one way or another. This group will be more open to credible information from a trusted source. Utilization of social media and other digital methods to convey infection prevention messages is an opportunity for health care organizations. Screen savers, social media posts, scannable QR codes that link to health messaging, and digital town halls are all innovative ways of engaging audiences.

Finally, a core competency for IPs is the need to emphasize pandemic response skills, risk mitigation strategies, infodemics, and risk communication. These skills are difficult to master but should be a part of every IP’s toolkit. As in any crisis, communication is a key to achieving the best outcome. IPs serve as a beacon for keeping science and evidence at the front of minds as information is shared.

REBECCA LEACH, MPH, BSN, RN, CIC, has been an infection preventionist since 2010 with a background in nursing and epidemiology. Leach, a member of the Infection Control Today® Editorial Advisory Board, works at a health care system in Phoenix, Arizona, that includes 5 hospitals and more than 100 outpatient treatment centers.

Words we’re watching: ‘Infodemic.’ Merriam-Webster. Accessed September 10, 2021. 

https://www.merriam-webster.com/words-at-play/words-were-watching-infodemic-meaning

Rothkopf DJ. When the buzz bites back.The 

https://www.washingtonpost.com/archive/opinions/2003/05/11/when-the-buzz-bites-back/bc8cd84f-cab6-4648-bf58-0277261af6cd/

Let’s flatten the infodemic curve. World Health Organization. Accessed September 10, 2021. https://www.who.int/news-room/spotlight/let-s-flatten-the-infodemic-curve

Eysenbach G. How to fight an infodemic: the four pillars of infodemic management. 

Reardon S. Flawed preprint highlights challenges of COVID drug studies. 

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Scales D, Gorman J, Jamieson KH. The Covid-19 infodemic - applying the epidemiologic model to counter misinformation. 

. 2021;385(8):678-681. doi:10.1056/NEJMp2103798

. September 8, 2020. Accessed September 10, 2021. https://magazine.jhsph.edu/2020/countering-infodemic

IPs know the reliable sources and are familiar with reading scientific studies and being able to translate those findings to staff in an understandable way.

How Infection Preventionists Can Battle Misinformation

COVID-19 could now be considered a vaccine-preventable disease (VPD), and with that designation comes an issue we have with other VPDs: vaccine hesitancy. The COVID-19 response has been rife with misinformation; what has been coined “the infodemic” has impeded effective and coordinated response efforts since before the virus was identified.

One year ago as of this writing, the idea of a COVID-19 vaccine was a hope on the horizon. When one was finally available, health care workers had a powerful tool that could help bring the pandemic to an end. I recall how I felt after receiving my first dose. Sitting in my car in the vaccine drive-through clinic, waiting for the obligatory 15 minutes after administration, I burst into tears. Months of anxiety, stress, fear, and hopelessness were released in that moment. I know many other health care workers who felt the same.

Now it is almost 9 months since the vaccine became available, and the nation is still struggling to reach high enough levels of vaccine uptake to meet population-level immunity. We are currently experiencing yet another surge, pushed on by the Delta variant, and health care as an industry is strained once again. There are some differences from our prior experiences: Hospitals are struggling with staff shortages, Delta is more contagious than earlier variants, and patients are younger and sicker. But perhaps the most significant difference in this surge is that we have a powerful weapon available at any drug store or provider’s office and many grocery stores: vaccination.

More and more states are making other preventive moves, such as masking, social distancing, and minimizing indoor groupings, obsolete through legislation and lack of enforcement. Vaccination is seen as a silver bullet that will end the pandemic. And yet public mistrust of the vaccine continues to pervade and affect public health care efforts. Individuals in states with lower vaccination rates have 4 times the risk of hospitalization with COVID-19.

Health care workers have been pushed to the brink in this marathon of pandemic response. Frontline and behind-the-scenes workers, mentally and physically at their limit, are again being relied on to take care of an influx of patients with COVID-19 as well as ones without the disease. As the Centers for Disease Control and Prevention (CDC) reports, this surge in hospitalizations is being driven by people who are not fully vaccinated. Does this perceived nonadherence affect providers’ ability to be compassionate to patients? If the means to prevent infection is freely available and people voluntarily refuse it, then do not take other measures to protect themselves and prevent infection, how can health care workers maintain professionalism and treat all patients equally?

We are here not to judge but to care for our patients. We often hear this comment now, as the talk at nurses’ stations and in break rooms can move to anger and apathy toward those who did not get vaccinated and are now filling the hallways of the hospital. Compassion fatigue, although not a new concept, may be more of an issue during this pandemic response. It is the emotional, physical, cognitive, and spiritual drain that results in the decreased ability to provide empathetic care to patients.

 Compassion fatigue can affect even the most dedicated health care workers and results from continued stress and long-term exposure to another’s suffering. Over time, without ways to cope with the stressors, health care workers can become detached and have trouble experiencing empathy and emotions when caring for patients. Results from prior studies, conducted prepandemic, found that nearly 40% of nurses had symptoms of compassion fatigue.

 One can imagine that percentage has increased dramatically throughout the past 18 months.

Empathy is a key piece in the healing and caring process for patients.

 Not only does empathy improve patient outcomes, it can also increase caregiver satisfaction.

 Unfortunately, health care workers who are experiencing compassion fatigue report distancing themselves from others, shielding from emotional connections with patients and families, and isolating themselves from others in their lives.

 All these symptoms directly affect their ability to have empathetic connections.

As health care professionals, we are taught to treat the disease and the patient and refrain from judging patients for the behaviors that led to their current situation. But over these past 18 months, with the continued bombardment of fear, anxiety of the unknown, and the struggle to regain some sense of pre–COVID-19 habits, health care workers have not been immune to the emotions the public is experiencing. And yet we are held to a higher standard. We have to set personal opinions aside and provide the best care for all patients, as well as, hopefully, some science and research–based education to help prevent future infection.

News articles and interviews are touching on compassion fatigue and some brave providers have spoken openly about these feelings.

 It is important to normalize and address the subject and the frustrations that are permeating the entire health care industry, not just the frontline staff. All the ancillary and support staff, including infection preventionists (IPs), have been called upon to support the work of frontline caregivers and are subject to the same stressors and potential for burnout.

IPs, as the subject matter experts, have similarly been called upon for other major disease outbreaks and pandemics, such as the H1N1 influenza and the Ebola virus. But the sheer duration of the pandemic response and its impact on all aspects of daily life have made this COVID-19 situation unique for many IPs.

Vaccination hesitancy among some health care workers is a topic that is not always addressed. It can feed into workplace stress and the formation of in and out crowds among health care teams. As more health systems mandate COVID-19 vaccination, the protests and complaints grow. Nurses and other staff members are quitting, with some suing, over vaccine mandates. Vaccine uptake among health care workers varies, with one health system reporting that more than 90% of physicians have taken the vaccine but only 50% or fewer nurses and aides have.

 What is sometimes forgotten is that health care workers are humans too, and although they have worked through these surges, a significant number do not trust the vaccines or may have concerns about their efficacy and adverse effects. Those who are angry about patients who refuse vaccination may also find it difficult to empathize with colleagues who refuse vaccination. Such divisiveness on hospital units can lead to communication and trust errors, which can directly affect patient care.

IPs have been trying to educate about vaccination as a public health tool for decades and are no strangers to the concerns raised about vaccines and mandates. Again, IPs are needed to help weed through the myths, misinformation, and political slants to make sure they can help patients understand the facts. But it’s not just patients who need the education, it is also staff and providers.

Media reports that sensationalize vaccine breakthrough infections and adverse effects and downplay the long-term effects of COVID-19 may also have an effect on the urgency people feel to get vaccinated. Sanjay Gupta, MD, chief medical correspondent for CNN, recently addressed the concern with the term 

, explaining how it has muddied the true purpose of vaccines and how effective the COVID-19 ones really are.

 According to Gupta, the term “doesn’t seem nuanced enough to describe what’s going on; it only serves to alarm those of us who are already vaccinated and potentially discourage those who are hesitant.”

The infodemic surrounding COVID-19 remains a challenge for IPs.

 Risk communication is a skill that many working in pandemic response have found valuable. One lesson from this deluge of misinformation is the importance of learning how to communicate during emergencies and become a reliable source of information. Risk communication is a skill that should become part of the core competencies of infection prevention programs.

IPs continue to be a source of knowledge about the epidemiology and prevention of COVID-19. They must find ways to share consistent and reliable messaging with staff and patients about how to stop disease transmission, the benefits of vaccination, and other public health efforts to control transmission. As Delta rips through the country and the fear of more mutations and variants of high consequence takes hold, we are working on borrowed time to push back against the virus and regain the public’s trust. The US Food and Drug Administration’s full approval of the Pfizer-BioNTech COVID-19 vaccine (other approvals may have followed after this writing), may help sway some of the public to get vaccinated, although it will not be enough to stop the current surge. IPs can help staff with compassion fatigue by having crucial conversations and speaking about the anger and betrayal they may be experiencing, all while being the calm in the Delta storm.

REBECCA LEACH, MPH, BSN, RN, CIC, has been an infection preventionist since 2010, with a background in nursing and epidemiology. Leach, a member of Infection Control Today®’s Editorial Advisory Board, works at a health care system in Phoenix, Arizona, that includes 5 hospitals and more than 100 outpatient treatment centers.

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All the ancillary and support staff, including infection preventionists, have been called upon to help support the work of the frontline caregivers and are subject to the same stressors and potential for burnout.

Vaccine Hesitancy and Compassion Fatigue: Infection Preventionists Battle Both at Once

Creating vaccines for coronavirus disease 2019 (COVID-19) and getting them approved by the US Food and Drug Administration (FDA) proved to be an arduous task fraught with scientific and logistical hurdles. Now comes the hard part: Getting those vaccines widely distributed to the right people. Where do infection preventionists (IPs) fit into this part of the pandemic response?

There are 2 overarching levels of vaccine implementation: regional public health mass vaccination planning and local, targeted efforts for specific populations. In both areas, IPs need to be involved in planning and implementation. IPs have both education and training in public health and outbreak response as part of their core concepts to become an IP. Also, many IPs work closely with local, regional, and state public health partners on a regular basis, so the relationships are already built.

The first wave of vaccination is focused on large-scale public health-driven efforts. These are being implemented at the state level for distribution to focus on healthcare workers and residents of long- term care facilities. These efforts clearly must be multi-disciplinary in order to have effective planning and viewpoints that can bring creativity to solve the problem of how to effectively distribute millions of doses of a vaccine that require very specific handling and storage parameters.

For example, the Pfizer-BioNTech vaccine requires ultra-cold storage and will be allocated in large dosage counts, requiring vaccination of large groups over a short time period. The teams need to include providers, pharmacists, public health, healthcare facility leadership, emergency management, and other local leaders. It is likely that members of these groups have not worked closely together before on such a large-scale task. It will be crucial to function with a hospital incident command system to keep the group moving forward with the same objectives and bring obstacles to the forefront quickly for rapid problem solving.

IPs have been working scenarios of mass vaccination for years, in preparation for pandemic flu primarily, but also with potential biological threats (anthrax, smallpox) and other outbreaks such as measles and pertussis. These skills and insights make IPs and their public health colleagues subject matter experts on the nuances of mass vaccination. For example, some hospital systems would take the opportunity to turn annual employee flu vaccination into a drill and treat it as if it were a mass vaccination event in collaboration with emergency management colleagues. These events would teach valuable lessons in the best way to reach all staff, including having multiple vaccination administration locations and the best way to handle the data collection necessary to track large scale vaccination efforts.

Infection prevention needs to be a partner in the large-scale planning that is occurring currently in most states and local healthcare facilities. These efforts are largely being led by public health on state or regional levels, but the local hospitals will also need to plan when vaccine is distributed in future tiers for local administration. Not only to help with logistics of vaccine storage, administration, documentation, and data collection and reporting, but also to focus on safety of the workers and vaccine recipients of the vaccine clinics. Staff use of personal protective equipment (PPE), workflow to ensure social distancing and decrease crowding, and cleaning and disinfection practices of the clinic site are all logistical concerns that should be addressed in the planning stage to avoid potential exposures or contamination concerns.

Another area for concern is the cold storage and transport of the vaccine. Specialized freezers and transport companies that can safely move vaccine shipments from distribution sites to clinics are necessary to maintain that cold chain delivery system. Specialized transport companies that have experience in this type of system will be in high demand and IPs can help evaluate the processes of these third-party vendors to ensure they will be able to accommodate the level of transport needed and maintain the storage parameters of the vaccines.

Data collection for the large-scale clinics will likely be mediated through health departments, but the details of tracking, knowing which employees did receive the vaccine, and communicating that to the local healthcare facilities will need to be addressed. Each state will likely have to determine the best way to communicate vaccine administration, but it will also be the responsibility of each employee to report their vaccination status back to the healthcare facility.

Hospital vaccine programs are historically a collaborative effort between infection prevention and employee health programs. As COVID-19 vaccine efforts continue, there will need to be consideration of how that will be managed within the context of the current hospital-based vaccination programs. How will a COVID-19 vaccine be handled at each facility? Will it be mandatory? Will it be given annually? Will it be a condition of employment? These are all questions that will need to be addressed. There are some unknowns at this point, including the need for annual boosters, required storage needs, and data reporting.

Infection prevention is also a key partner with employee health programs to promote vaccine uptake and educate on the mechanism of how the vaccine works and potential side effects. As these new vaccines are approved for distribution, it will be key for IPs to learn about the studies completed to date to have an understanding of these key points to help with staff education. Reviewing the articles published during the trials, as well as the recommendations from the federal programs will help IPs become knowledgeable about the vaccines. Also, key information that IPs will likely need to address will be side effects, efficacy, and recommendations of priority risk groups (such as healthcare workers, elderly, essential workers, etc). IPs can help address these questions through rounding and education opportunities, published newsletters and new employee orientation.

Planning for the logistics of how vaccine will be distributed locally will take much effort. Some items to consider are the timing of when staff will receive their dose and when they work their next shift. As virtually all healthcare facilities are screening for COVID-19 symptoms, the reactions to a vaccine may potentially meet some of those criteria, such as low-grade fever or malaise. It will be important to plan for this as an organization, to consider that with screening or plan for staff to have 24-48 hours after their dose before their next shift. The calculations will also need to include the fact that the vaccines are given in 2 doses.

Planning for this process should already be starting. As many healthcare facilities are operating under the hospital incident command system, the vaccine administration can be brought under that structure and would already have all the key departments at the table to help coordinate.

Data reporting for COVID-19 vaccination will likely be extensive. Many employee health programs may not have the reporting capabilities to handle the level of data collection and tracking that will be necessary for this initial wave of vaccination. Often employee health programs do not have electronic systems that integrate with other reporting programs or link to state health departments, therefore much of the work will be manual. Infection prevention needs to advocate for improved data systems for employee health tracking, which will not only be beneficial in the COVID-19 vaccine process but, going forward, for all other employee health activities.

One thing that IPs must remember: Vaccination is not the end of this pandemic. Most likely, the vaccination rate needed to provide sufficient population immunity to control spread is around 80%.1 It will take years to achieve that level of vaccination, if at all. So, the vigilance of basic infection control measures will need to be maintained in some fashion until such a point. This is part of the IP toolkit.

Having worked with vaccine preventable diseases for decades, IPs understand that vaccination is not the only way to prevent disease transmission.

Behavior modification, engineering controls, such as modifying traffic patterns and increasing ventilation air exchanges, and other active processes are key to a multi-focal prevention plan. Universal masking will continue in healthcare facilities and hopefully on a community level for some time, until population immunity is of a sufficient level or community spread is low to minimal.

1. Bartsch SM, MPH, O’Shea KJ, Ferguson MC, et al. Vaccine efficacy needed for a COVID-19 coronavirus vaccine to prevent or stop an epidemic as the sole intervention. Am J Prev Med. 2020;59(4): 493–503. doi: https://doi.org/10.1016/j.ajic.2020.10.018

How will the COVID vaccine be handled at each facility?  Wil it be mandatory? Will it be given annually? Will it be a condition of employment? These are all questions that will need to be addressed.