By Kelly M. Pyrek
Promoting the value of infection prevention programs and securing the resources necessary to ensure the continued viability of such programs has become an imperative for the infection preventionist (IP) in the era of healthcare reform and increased demands on IPs' time. A new guidance document aims to provide an updated assessment of the resources and requirements for an effective infection prevention and control/healthcare epidemiology (IPC/HE) program.
Kristina A. Bryant, MD, a pediatric infectious disease physician at the University of Louisville School of Medicine in Louisville, Ky., and her colleagues have updated the Society for Healthcare Epidemiology of America (SHEA)'s 18-year-old document, "Requirements for infrastructure and essential activities of infection control and epidemiology in hospitals: a consensus panel report" (Scheckler, et al. (1998). As Bryant, et al. (2016) explain, "Nearly two decades later, transformative changes have taken place in healthcare and these changes have substantially increased the responsibilities and workload of infection prevention and control (IPC) programs. This evolution has included new challenges for IPC/HE pro-grams unheard of at the time of the original publication, including legislative mandates, public reporting, pay-for-performance, payment penal-ties, healthcare-associated infection (HAI) prevention collaboratives, bioterrorism, new and emerging pathogens, Occupational Health and Safe-ty Administration mandates, and the first National Action Plan to reduce HAIs. Concurrently, the rising frequencies of multidrug-resistant organisms (MDROs), unprecedented antimicrobial shortages, and a relative lack of new antimicrobials have further tested IPC strategies. Many of these challenges have necessitated increased education and training. In fact, there is ample evidence that a comprehensive IPC/HE program can reduce HAI, minimize the spread of MDROs, and address emerging infections and pathogens, ultimately keeping patients safer."
At the heart of the document is the concept that the scope of a healthcare institution’s IPC/HE program should be driven by the size and complexity of the patient population served, that population’s risk for healthcare-associated infection (HAI), as well as local, state, and national regulatory and accreditation requirements. Bryant says that a truly effective IPC/HE program must be multidisciplinary and that program personnel "must have authority delegated from institutional leadership to perform essential activities and implement change to reduce HAIs. The number of personnel is determined not solely by the number of patients served by a given facility, but rather by the scope and complexity of program activities. The budget allocated for the program must support adequate numbers of personnel to execute program activities. At present, many healthcare institutions are under-resourced, with insufficient reimbursement for hospital epidemiology services and too few infection preventionists."
No one has to tell an IP that his or her day has become busier than ever before; the impending results from the meg-survey of IPs from the Association for Professionals in Infection Control and Epidemiology (APIC) will be the latest in a number of projects and papers that have documented the burgeoning responsibilities of the IP. Let's take a look at a few of these core tasks:
- Surveillance, and all that it encompasses, including case finding, data collection and analysis, and reporting these findings -- is one of the cornerstones of the IP's responsibilities, and this outcome date is often coupled with risk assessment activities in order to identify the most important populations and infections to monitor so that resources can be focused on the most worthwhile prevention activities. As Bryant, et al. (2016) observe, "'Important' typically translates into those populations most vulnerable to HAIs; infections that cause the highest morbidity, mortality and expenditure of healthcare resources; the organisms that are most concerning for populations the facility serves, including MDROs; and organisms most likely to put healthcare personnel (HCP) at risk for disease. By necessity, the risk assessment must also consider requirements of external agencies, payers such as Centers for Medicare & Medicaid Services (CMS), and state-based legislative mandates."
- Public reporting requirements are also demanding more of IPs' time and attention. As of March 2014, 31 states had enacted laws that re-quire hospitals to report HAI data to the National Healthcare Safety Network. Pay for performance has become an integral part of healthcare quality improvement, with Centers for Medicare and Medicaid Services (CMS) Conditions of Participation for Hospitals and its Conditions for Coverage for Ambulatory Surgery Centers requiring that healthcare organizations must meet these conditions in order to be Medicare- and Medicaid-certified and receive reimbursement. In addition, under its inpatient quality reporting mandates, CMS is currently requiring acute-care facilities to report CLABSI, catheter-associated urinary tract infections, and select surgical site infections, as well as hospital-onset Clostridium difficile infection and hospital onset methicillin-resistant Staphylococcus aureus bloodstream infection, while long-term care hospitals, skilled nursing facilities, acute care cancer hospitals, and inpatient rehabilitation facilities are also required to report specific HAIs. The Affordable Care Act provisions include a mandate that facilities within the highest quartile for certain infections be penalized 1% of their Medicare reimbursement. As a result, the quest for quality improvement has reached the IPC/HE programs. As Bryant, et al. (2016) note, "The power and efficacy of HAI surveillance lies in sharing findings with direct care providers who can use such findings to improve the safety and quality of care. Performance or process improvement initiatives can help busy healthcare teams to integrate prevention measures into their daily practice and ultimately reduce HAIs. Understanding, leading, and facilitating process improvement using methods such as “plan, do, study, act,” “plan, do, check, act,” or more recently the 4-Es model (“engage, educate, execute, evaluate”) are key functions of contemporary IPC/HE programs.15 Process mapping and other tools are used to identify and remove barriers to effective systems and processes that impact outcomes of care. Tools to eliminate waste and reduce process variation, such as Lean and Six Sigma, have been adopted from other industries to create more efficient work flows and improve adoption of practices that reduce HAIs. Process improvement initiatives may be driven by suboptimal results identified by surveillance or process data or during annual risk assessment and plan evaluation, an organization’s strategic priorities, as well as regulatory and accreditation requirements."
- Outbreak investigation and response is another key responsibility of IPC/HE programs and may require a significant proportion of a pro-gram’s resources. Additionally, emergency preparedness and response is a related but distinct function of most programs and may be associated with novel or emerging pathogens, agents of bioterrorism, or infectious disease outbreaks following natural disasters.
- Providing those teachable moments on the floor, as well as offering more structured education and training programs such as in-services are what Bryant, et al. (2016) describe as "critical functions to prevent HAIs and core functions of IPC/HE programs." They add further, "Regula-tory and accreditation agencies such as CMS, the Occupational Health and Safety Administration, and the Joint Commission require routine training in infection prevention, and focused training for various disciplines has been effective in achieving sustained reductions in HAIs. Nevertheless, there is increasing recognition of the need for improved education and oversight among HCP in a variety of settings. Ongoing lapses and major errors in infection prevention efforts … demonstrate a lack of basic infection prevention practice and processes in many cases. Continued transmission of MDROs and influenza in healthcare settings resulting from poor adherence to hand hygiene and other infection control measures also demonstrates a need to reevaluate the educational approach. Experts in IPC/HE should lead curriculum development for HCP infection prevention education. Routine in-service training should be directed toward HCP of all disciplines, including physicians, nurses (registered nurses, licensed practical nurses), and other HCP with direct or indirect contact with patients or equipment (environmental services work-ers, instrument reprocessing staff, dietary personnel) and should be tailored to the appropriate educational level, learning styles, and work du-ties. This training should incorporate evidence-based practices to reduce HAIs, including hand hygiene and all tasks for which personnel are responsible, and incorporate assessment of well-defined competencies for each task."
- Adjunct activities are also numerous and can include occupational health services, antibiotic/antimicrobial stewardship initiatives, and participation in regional and national collaboratives to improve patient outcomes.
Stretched thin, more IPs are feeling as though they spend more time collecting and processing data than they do protecting patients. A case study presented last year at the annual APIC meeting (Oral Abstract #030: The Burden of National Healthcare Safety Network (NHSN) Reporting on the Infection Preventionist: A Community Hospital Perspective) showed that collecting and reporting hospital infection data to federal health agencies takes more than five hours each day, at the expense of time needed to ensure that frontline healthcare personnel are adhering to basic infection prevention practices such as hand hygiene.
IPs at Robert Wood Johnson University Hospital Somerset tabulated the amount of time necessary to review lab data and complete re-ports for bloodstream infections, urinary tract infections, surgical site infections, MRSA infections, and Clostridium difficile infections to the Centers for Disease Control and Prevention (CDC’s National Healthcare Safety Network (NHSN).
“HAI reporting exposes problems, drives improvements, and allows for benchmarking against national targets. But without adequate staffing, the burden of reporting takes time away from infection prevention activities that protect patients at the bedside,” says Sharon L. Parrillo, BSN, RN, CIC, assistant director of infection prevention at Robert Wood Johnson University Hospital Somerset in New Jersey. “We are fortunate that we have two IPs on staff at our hospital, but many community hospitals have only one staff person dedicated to infection control. This analysis didn’t even take into account the time necessary to perform state and local HAI reporting, which many facilities are also required to do.”
Parrillo calculated the number of laboratory test reports—urine, blood, wound, and sputum—received and reviewed in July, August and December 2013, and January 2014 at her 355-bed acute care community hospital. Using NHSN time estimates for each infection event report, she calculated the total amount of time needed to review the lab reports and complete reporting using the NHSN criteria and definitions. This totaled 118.29 hours each month—or five hours and eight minutes per day, based on a five-day work week. It is also worth noting that during the time period assessed, the hospital was only at 60 percent capacity.
“I hope this study encourages lawmakers to consider the burden of IP time when new HAI reporting legislation is being considered, and helps IPs at other facilities start a conversation with their leadership about staffing and resources needed to ensure a safe environment for patients and staff,” notes Parrillo. “Much of what I do involves sitting at a desk. It’s frustrating, because that’s not how I can prevent infections. We need to be able to do more rounding, more hand hygiene observance, more preparedness, and more staff education.”
Bryant, lead author of the updated SHEA guidance, says, "I think most of us realize there is this tension that exists between competing demands for the IP. Historically, a huge part of the infection preventionist's work has revolved around surveillance and collecting the data, and so that remains very important, but I think everyone recognizes that the IP doesn't need to be sitting at a desk, poring over charts and print-outs most of the day. They are most valuable when they are out there, working with frontline personnel, observing and teaching. Although surveil-lance is important, going forward, we need to look at how technology can help us by streamlining the work of the IP to free them up to go out on the floors, do quality improvement work and thereby effect change." Bryant continues, "There are some valuable resources in this guidance document, including a section on information systems and links to other papers about how electronic resources can facilitate the work of the IP, so that they don't have to spend a huge chunk of their day tied to the computer."
The utilization of infection prevention must be balanced with corresponding resources. The updated guidance document from Bryant, et al. (2016) outlines the personnel, physical, and financial resources required for an effective IPC/HE program and emphasizes that "The individual(s) responsible for leadership of the program must be clearly identified and have significant access to key organizational leaders and clinical decision makers."
The basic personnel requirements of the IPC/HE program include the infection preventionist, the healthcare epidemiologist, the infection prevention liaison and additional support personnel as warranted.
- The IP: It has been several decades since the Study on the Efficacy of Nosocomial Infection Control (SENIC) first identified the principle that IPs were key drivers of an effective program (Haley, et al. 1985). In the years since, APIC has developed core competencies for the novice, proficient, and expert IP (Murphy, et al. 2012; APIC, 2012), which outline the skills needed to advance the infection prevention field and was created to help direct the IP’s professional development at all career stages. As Bryant, et al. (2016) acknowledge, "Over the past several decades, the amount and complexity of the IP’s work has increased dramatically and many IPs now provide oversight to an expanding network of affiliated ambulatory-care facilities in addition to the core inpatient facility. The complexity and intensity of patient care delivery, increasing severity of illness of the patient population at risk and use of invasive devices, increasing activity related to the delivery of healthcare beyond the traditional hospital walls, and mandatory reporting of HAIs are only a few of the reasons for the expansion of the IP’s responsibilities."
- The HE: As Bryant, et al. (2016) point out, "The importance of physician leadership in IPC/HE program was recognized as early as the 1960s when published conceptual models called for a physician infection control officer to perform most surveillance and control activities. The Study on the Efficacy of Nosocomial Infection Control project identified that a physician with training in HE is an essential component of a hospital infection prevention program and programs led by a physician with expertise in HE had lower rates of HAIs. Today, physicians who fill the role of healthcare epidemiologist/medical director of infection prevention may share oversight of a facility’s infection prevention program with an IP manager/leader. Duties of hospital epidemiologist/IP teams often include strategic planning, leadership of quality/performance improvement initiatives, and communication with facility administrators."
- The IPC Liaison: IPC/HE programs need additional personnel to support administrative tasks and help manage priorities so that IPs and HEs can focus on responsibilities that drive improvement that lead to better patient outcomes. As Bryant, et al. (2016) explain, "Designating health professionals involved in direct patient care as IPC liaisons has been reported to be an effective adjunct to enhance IPC at the unit level. Such individuals receive training in essential elements of IPC and have frequent communication with the IPC/HE program but maintain their primary role as direct caregivers in the areas they work. Liaisons can facilitate awareness of IPC at the point of care and assist with implementation of new policy, intervention, or practice changes; provide point of care education; and share surveillance findings. Liaisons can serve as an adjunct to, but not a replacement for, fully trained IPs, and liaison nurses should not be considered when assessing IP staffing."
Without the proper personnel in place, the demands of the job can feel overwhelming. "There is a tremendous amount of work to be done each day," acknowledges Bryant. "One thing that has become apparent is that the skills of the IP and HE are critical to any facility's overall patient safety and risk management program. So I think that is part of why the scope of the IP and the HE has expanded. Because IPs and HEs bring valuable skills to the table consistently, the organization may be tempted to say, 'Hey, you are really good at this, so here's another project that meets your skill set.' So perhaps the answer is to say, 'Maybe there needs to be more of us -- both IPs and HEs -- in order to cope with increasing demands on this department. And what have we learned from the recent past? You never know what's around the corner, so we need to be nimble and have enough resources to get our day-to-day work done but also respond to new re-emerging organisms. We need to have enough 'give' in our system to be able to respond adequately and appropriately."
Direct collaboration between the IP and HE can also help to blunt the impact of the increased demands on the IPC/HE program. "I think it is critical to develop and maintain a partnership between the IP and HE," Bryant confirms. "We already knew back in the 60s that physicians leadership -- and as a co-leader with an IP -- was important. Since then, there has also been the realization that an HE is not just an infectious disease (ID) physician who agrees to do this for the hospital; in the past, it was assumed that the task of healthcare epidemiology could be assigned to any ID physician who may or may not have had training in healthcare epidemiology. There is now the realization that this is truly a very specialized area of infectious diseases and the HE brings unique skills to the task. In my own hospital, an infection occurs, we do an investigation and we spend a lot of time on nursing processes; well, the problem with that is not all infections in the hospital are related to nursing practice -- physicians also contribute to the care of patients and whether or not they get an infection. Having a physician leader is helpful in engaging the medical staff in infection prevention efforts; healthcare workers are a diverse community and I think having a physician-nurse dyad to lead the program speaks to our constituency."
Adequate personnel must be accompanied by adequate budgets and resources. One big area is information technology and health informatics, and as Bryant, et al. (2016) observe, "IPC/HE programs are now tasked with significant escalation in the collation, analysis, and timely reporting of surveillance data. Informatics systems and networks are an increasingly critical element of the program infrastructure. IPC/HE pro-grams are meeting these increasing informatics needs with homegrown systems that require resources for construction and maintenance. In addition, many sites have purchased third party infection control vendors that enhance existing electronic medical records and homegrown systems. Applications that can tie a laboratory information system, admission/discharge/transfer, imaging results systems, pharmacy, microbiology, and so on into a single data network are needed by IPC/HE programs. Well-run systems increase the efficiency of the HAI surveillance system. Eliminating manual review of microbiology reports or other paper records frees up the IP for more collaboration with clinicians and al-lows them to embark on other endeavors that may have the greatest impact on patient outcomes."
The researchers continue, "Without appropriate funding, IPC/HE programs will be unable to perform effectively. Finance and accounting departments can assist in the preparation of the business case for IPC/HE program resources as they will have access to data about dollars lost due to HAI through pay-for-performance and penalty programs. They can promote understanding of the return on investment of the IPC/HE program."
Bryant says she frequently hears that many IPC/HE programs are under-resourced, and hopes that healthcare professionals will consult Table 3 in the guidance document in order to take stock of their program needs and current resources. "I am hoping that Table 3 in the paper will really cause some eyes to open," she says. "Some people in the healthcare setting still don't know what the IP does; they think they merely collect line days and report infections and take care of outbreaks -- that is just a tiny part of what the IP does, so table 3 speaks to the scope and value of the IP, and we’re hoping that ultimately, that could lead to increased attention to what resources the program really needs."
Bryant says she hopes the guidance document will be beneficial to a wide range of healthcare stakeholders. "I think that there are different audiences for this document. We hope that it will be read by hospital administrators who will say, 'Wow, the scope of infection prevention and healthcare epidemiology is huge and this is what a program should look like, here are the needs, and here are the resources.' We hope this will be a valuable tool for people on the frontline to be able to have an honest discussion with their administrators; it's important for them to be able to say, 'Here are the resources that we need, here are examples of why we need them, this is the important work that we do.' We felt that the 1998 paper was trying to prove why infection prevention and healthcare epidemiology is important; for the update, we didn't feel like we needed to do that again -- everybody knows the value of the program. We did believe, however, that it was time to renew the discussion about necessary resources."
Making the business case for IPC/HE programs is essential, Bryant adds. "All of us need to be upfront with our administrators about what we do and why it is of value to the organization. Administrators have a lot on their plates and they must respond to diverse needs and this is probably true in any business or industry, not just healthcare. So we must make sure that those at the top understand what value we bring to the organization. Potentially, we don’t get a lot of training in how to do that, but I do think it's critical."
Bryant continues, "Pay-for-performance has highlighted the importance of infection prevention and healthcare epidemiology; there is a lot of understanding about the human and the financial costs associated with healthcare-acquired infections -- I think that has definitely bubbled to the surface and is on everyone's radar. But I think the flip side is that our duties continue to expand. There was a paper in ICHE last year that addressed the Ebola epidemic and how it created a whole new arena for infection prevention and healthcare epidemiology to work in and new responsibilities and often without a lot of resources -- we had to figure out how to make that happen. Pay-for-performance has helped us to take the initial steps to make a solid business case, and this guidance document further underscores the key message of the scope of the IPC/HE program and that the resources need to be proportional to what you are really asking people to do and the complexities of the populations they serve."
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