Brooke Decker, MD, is the director of infection prevention at the VA Pittsburgh Healthcare System. Infection Control Today®’s Editorial Director Alexandra Ward recently spoke to Decker about the many demands placed on infection preventionists during the COVID-19 pandemic. Decker talked about those demands and challenges, but she also spoke about how the crisis might reinforce the importance of infection prevention and infection preventionists in healthcare settings. Decker: “I think the best advice I can give is, ‘Hey, this is what we trained to do.’ Keep your spirits up, help keep the spirits up of the other people in your hospital.”
Infection Control Today®: Can you start off by telling us a little bit about what your day-to-day is like in the middle of this pandemic?
Brooke Decker, MD: Absolutely. And thank you so much for inviting me. So, I tried to think about what does my day look like? Like any other infection prevention person, you really never know what your day is going to look like. But in general, I come in, I check with the on-call infection preventionist RN to find out what happened overnight. Sometimes I might already know, but there might be some additional things that we can go over. The next thing I do is I sit down and generate some data. As the hospital epidemiologist, I have to provide my leadership team with some information. They want to know how many cases came in, how many tests the lab ran. Really many different things might be on my agenda for what kind of data they’re looking for, for their morning meetings. The next thing I do is we have an IP team huddle every single day. And we get together and go over what we plan to do, make sure we’ve divvied up the labor, every meeting is covered. And then we also go over any questions. Of course, the clinical teams are asking us all kinds of excellent questions that maybe we haven't encountered, or we just want to make sure we consistently answer them when there isn’t clear guidance, and it's somewhat based on judgment. We want to make sure we’re producing the same judgment every time it’s asked. So, we have a wonderful huddle call. I highly recommend a morning huddle call with your IP team if you can have one. And after that, it’s on to the telemeeting marathon.
ICT®: COVID has really put the spotlight on infection control as an industry. Have you seen this as an opportunity to educate and, in some cases, maybe re-educate healthcare workers on the importance of infection control and prevention?
Decker: Absolutely. And I think every good infection preventionist uses every opportunity to educate. I can say that this pandemic has really made people a lot more receptive to infection control practices when they may not have been before and we have to use that energy. There are people bringing me great questions. Sometimes those questions, I’m going to answer in a way that maybe isn’t where they were going. But I really try to validate their concerns, even when they’re asking me can I wear a spacesuit to go pick up my mail? I say things like, “Wow, you’re really thinking like an IP now? Here's what we should do.” And that way, you’re sort of more agreeing with them and then moving them where you need them to be to align with appropriate guidance and PPE usage. Rather than feeling like you’re shutting them down. I really think we have to use that enthusiasm and complement them and say while you’re doing it, here’s where we’re going to go. I think IP has got to take an active role in teaching, evaluating, reinforcing policies. Obviously, many of us…. I’m especially chained to my desk. But fortunately, my RNs are not as chained to their desks. They’re able to go out to the units and see what’s going on. Hear those frontline people saying, “You know, I know that policy you made really sounds great on paper, but here’s my problem.” And we need to be there to say, “Oh, goodness, OK, we’ll rewrite that and here’s how we can make it work.” I think there are a lot of IP programs that are doing more telework. I say that I am fortunate to have a good sized team and some of my people are teleworking at any time, but I still have people on the ground every single day in order to be there with those frontline providers to see what they’re going through and answer their questions. It’s been very challenging as well to address some of the concerns of the frontline staff, because from their perception, things are changing all the time. I think we don’t know a lot about this pathogen. And I admit that I say, we’re going to know a lot more in two to three years. Unfortunately, we need to make a decision today. Here’s the decision that we're making. And I always also like to reassure people I know … I know everyone in IP is busy right now. And people are often reaching out to us saying, “I’m so sorry to bother you. And I say, “No, no. IP is here to help.”
ICT®: What do you think the new normal of infection prevention will look like? Will this sort of pandemic level of IP sustained even after the case count starts to drop?
Decker: It’s really hard to predict what’s going to happen in the next month, year, or multiple years. I do think there are going to be things that are going to change indefinitely. I’ve been starting to think and talking to colleagues who’ve been here longer and gone through past epidemics. Thinking like the HIV epidemic. Before the HIV epidemic, we didn't have standard precautions. Standard precautions came out of that. Obviously, I can’t predict for sure what’s going to happen. But one thought I have is perhaps we’re going to have a new standard precaution. It’s going to incorporate more respiratory precautions. But I think we're just going to have to see what we learn and what happens.
ICT®: How do you assess barriers to infection prevention within your healthcare system?
Decker: I have to say that I am incredibly lucky in my healthcare system that I have an incredibly strong connection with my leadership team. I participate as the subject matter expert in our hospital incident command. For this outbreak, I recommend that all IP departments advocate for at least a weekly meeting with their leadership official. If it isn’t already happening right now. IP is crucial for ensuring quality patient care. Most hospital systems will recognize that and make themselves available. If not, you have to remind them that they make themselves vulnerable by not having a strong IP program. This is a time where you need to advocate for the people you need. If before this pandemic happened, you were saying, “Well, if only I had one more infection preventionist here to help me.” “If only I had a data person.” “If only I had a physician medical director.” I’m sure you’re hurting right now. And this is the time to bring that to your leadership person and say I need this position now. This is not going to end in the next week. It’s not going to end in the next month. It’s going to go on until we have an active vaccine. So, this is a great time to bring that up and get the people that you need.
ICT®: How can infection preventionists ensure that protocols are being updated to reflect any new guidance coming out?
Decker: The first thing I have to say is read, read, read. A large portion of my day is reading all of the new guidance that is coming out. Wherever you get your information … certainly you have to read the CDC. Any policies coming from your policy or from your hospital system. But also looking at infection prevention journals that you like to read. Looking at whatever listserv. I think if you’re not involved in an infection prevention listserv forum, or other group that allows you to talk to your peers and offer sort of those questions that maybe aren’t in the guidelines, you need to be on one and then keep up to date with them and see what’s being said. Then the next step after you read, read, read is update, update, update. If you have any policies, I would look at them every week at a minimum. I think there are always a few things when I review policies that I could update on them. I send them to my team when I update them. And I make sure that I get thoughts from other people. You know, if you’re writing a policy about what to do in the emergency room, you probably need to have not just the emergency room medical director, but make sure you have the head nurse in the ER. Make sure you have respiratory therapy. Make sure you have other groups that are going to be involved and affected by that policy. And then I think anything you have.… If you have a policy that’s dated—and, of course, all your policies are dated—if it’s dated any more than two weeks, I probably need to update that. I will admit that the frequency at which I make tweaks to policies might drive some people crazy. But I think that we need to also make sure, because we don’t know everything about this disease right now. We're going to learn new things and those new things are going to probably impact how we want to approach it and I think that’s the right thing to do. I would not stick to a policy just because we’ve already trained everybody on this. That’s not the right approach in my mind.
ICT®: Has your institution faced any shortages of PPE? And, if so, how do you navigate that?
Decker: So very fortunately, we are in a conservation mode, but we went into conservation mode early. My approach was seeing this coming you can’t conserve after you run out. An example would be that at the VA Center, we are still isolating for MRSA and VRE. Fortunately, our national office came out with guidance saying, “If you want to walk back from that MRSA and VRE contact precautions in order to conserve your materials you can.” We jumped right on and said, OK. I’ve talked to colleagues who also have gone away from MRSA and VRE contact precautions and other centers and had really good outcomes based on that. Certainly, looking at other hospitals, where providers are having to wear non-standard PPE, breaks my heart and I never want to be there. And fortunately, we’re not there. Pittsburgh is also not a very hard-hit location. Our cases have been very manageable. We are not out of any PPE. And the VA is also very fortunate in having a very large established network. And we have great coordination in getting supplies to areas with greater needs, and specifically, our facility has been able to share with other harder hit facilities on the east coast.
ICT®: There was a recent article piece in a peer-reviewed journal that proposed universal face shields even out in the community. What are your thoughts on some of those other containment measures?
Decker: We’re currently using face masks as the ideal face covering, including the fabric mask for the patients, family members, and non-patient care employees that we have. For people who aren’t able to wear face masks, we are approving a full-face shield. Reasons to not be able to wear a mask would include pulmonary issues, PTSD and other things that would prevent you from being able to wear a face covering. We are adding the caveat that a full-face shield is not acceptable in patient care. You do need to be wearing a mask and then to try and stay six feet away from other people. Because a face shield will certainly cover what’s coming at you. But it’s possible that your respiratory droplets could fall down and go to the side. We don’t see it as the equivalent to a face mask. But, certainly it’s a great measure. And I think, also dealing with patients, I think that's a challenge. I think most patients are going to be able to wear a face mask when they come into the hospital, but some patients aren’t. And having that secondary idea of, well here, let’s give you a face shield. It’s better than nothing. I think that’s where I kind of see it as better than nothing.
ICT®: And lastly, what is your advice to your fellow infection preventionist professionals and healthcare workers right now?
Decker: I think the best advice I can give is, “Hey, this is what we trained to do.” Keep your spirits up, help keep the spirits up of the other people in your hospital. Remember, if you’re not having fun, I’m sure they're having a lot less fun because this isn’t their area of expertise. And also keep in mind that right now you’re generating those stories that you’re going to be telling junior colleagues for decades to come. Probably until they’re bored of it. I would sort of approach this from like, “You’re making history right now. You’re doing things that you’re going to reflect on for the rest of your career.” If you have junior IPs in your in your group, and I do, I try and say, “Oh, this is wonderful. You’re learning so much. You’re learning all of IP in a short period of time. Wonderful!” But I think trying to see the bright side of things and appreciate the small victories that you get. You know, if you get another position from this, if you get an opportunity to talk to leadership, if you get to participate in a group that you hadn’t … if you make that connection with someone in a department that you didn’t know before, but now you’re like: “OK, next time I have a problem when the ceiling starts leaking, I’m going to be calling that guy.” You know, you may be able to meet people and other IPs to that you didn’t know before, and they may help you in the future.
This interview was edited for clarity and length.