By Kelly M. Pyrek
The healthcare landscape is, of course, very different today than it was 40 years ago, when a landmark study first called for the involvement of an individual tasked with paying attention to infections in the hospital environment. As Dhar, et al. (2016) observe, "Infection prevention programs (IPP), now a standard in healthcare, saw their inception in the1970s and 1980s after studies (such as the CDC’s Study on the Efficacy of Nosocomial Infection Control [SENIC]) showed a 32 percent reduction in HAIs in hospitals with established programs compared with the 18 percent increases in infection in hospitals without." In the ensuing years, the National Nosocomial Infection Surveillance System for voluntary reporting of surveillance data was created, the Joint Commission has introduced accreditation into the picture, and, as Dhar, et al. (2016) point out, "Since this time, there have been several groups that have had direct influence on the development of IPP ranging from professional societies, government agencies, nonprofit organizations, and payors. This complex landscape for infection prevention has led to the development of quality initiatives, legislative reforms, shifts in payment for HAIs, and an increased demand for transparency through public reporting of HAI data."
Dhar, et al. (2016) allude to the significant imprint that healthcare reform has made on infection prevention and control (IPC) programs: "Healthcare reform in the first decade of this century (such as the Deficit Reduction Act of 2005 and the Affordable Care Act of 2010) and the categorizing of HAIs as preventable, have led to a paradigm shift in the reporting of and reimbursement related to these infections. Beginning Oct. 1, 2007, the Department of Health and Human Services/CMS, in consultation with the CDC, began to select hospital-acquired conditions (HACs) to target for reduction. These conditions had to meet the following criteria: (a) be high cost, high volume or both, (b) require a higher paying diagnosis related group when present as a secondary diagnosis, and (c) could reasonably have been prevented if optimal healthcare practices had been followed. If not present on admission, such HACs would not be reimbursed to hospitals."
In an era of value-based purchasing and pay for performance, Dhar, et al. (2016) note, "…this is an exciting but challenging time for infection prevention and control. The past decade has witnessed changes in the way that hospital-associated infections are viewed—from passive acceptance to the stout view of preventability, leading to policy changes, transparency, and increased collaboration among various agencies at federal and state levels. IPs remain in the crossfire of regulatory bodies and payers such as JC and CMS, manifested by increasing regulatory requirements and hospital efforts to meet the elusive goals of 'zero infections.' As such, these programs have a unique opportunity to impact and reshape the way that health care is delivered, and to create a safer environment for patients and healthcare workers."
Fast-forward to mid-2017, and not that much has changed, as infection preventionists still focus on a primary goal -- the protection of the healthcare personnel and patients; except now, the aforementioned healthcare landscape is foisting upon IPs additional domains of responsibilities that compete with observational rounding and teaching. To seemingly address this tension among tasks, this year the World Health Organization (WHO) provided new guidance to prioritize the development of global recommendations on the core components of effective IPC programs both at the national and acute healthcare facility level, based on systematic literature reviews and expert consensus. WHO issued 11 recommendations and three good-practice statements in a guidance crafted by Storr, et al. (2017), who observe, "With the exception of a set of IPC core components previously identified by experts during a WHO meeting, there is a major gap in international evidence-based recommendations as to what should constitute the key elements of effective IPC programs at the national and facility level."
The authors of the new WHO guidance say it builds on the initial momentum of the WHO IPC core components interim document published in 2009 and that the recommendations were based on the best available scientific evidence and expert consensus "with the ultimate aim to ensure a high quality of health service delivery for every person accessing healthcare, as well as to protect the health workforce delivering those services."
Bubb, et al. (2016) say that "IPs shall systematically evaluate the effectiveness of the program and its appropriateness to the practice setting. In particular, IPs shall: develop and review the effectiveness of the program’s goals and objectives; ensure that customer needs and expectations are considered in the development of and continuous improvement of processes, products, and services; and determine resource needs to accomplish the proposed goals and objectives."
The WHO guideline says that IPC programs are one component of safe, high-quality health service delivery, yet Storr, et al. (2017) point out that a WHO global survey published in 2015 revealed major weaknesses in national IPC capacity; among the 133 respondent countries, only 54 had a national IPC program (41 percent) in place and even fewer reported a program in all tertiary hospitals (39/133; 29 percent). The WHO guideline recommends that an IPC program with a dedicated, trained team should be in place in each acute healthcare facility for the purpose of preventing HAI and combating antimicrobial resistance through IPC good practices. The WHO guideline supports the establishment of stand-alone, active national IPC programs with clearly defined objectives, functions and activities for HAI prevention, and that they should be linked to other relevant national programs and professional organizations.
The WHO guideline states that the availability of technical guidelines consistent with the available evidence is essential to provide a robust framework to support the performance of good practices. As Storr, et al. (2017) note, "Importantly, the existence of guidelines alone is not sufficient to ensure their adoption and implementation science principles and findings clearly indicate that local adaptation is a prerequisite for successful guideline adoption. The WHO inventory identified that on average, 74 percent of national IPC documents addressed the development, dissemination and implementation of technical guidelines and 43 percent emphasized the importance of local adaptation. Over 80 percent of national documents addressed the need for the training of all staff in IPC measures." The WHO guideline recommends that evidence-based guidelines should be developed and implemented for the purpose of reducing HAIs and that the education and training of relevant healthcare workers on the guideline recommendations and the monitoring of adherence with guideline recommendations should be undertaken to achieve successful implementation.
Education and training is the cornerstone of HAI prevention, and the WHO guideline recommends that IPC education should be in place for all healthcare workers by utilizing team- and task-based strategies that are participatory and include bedside and simulation training to reduce the risk of HAI and antimicrobial resistance. As Bubb, et al. (2016) note, "IPs shall act as educators and be a resource and catalyst for change for healthcare providers, ancillary staff, patients, families, and the general public. IPs shall also be knowledgeable and well versed in the foundations of IPC, including identification of the infectious disease process and how to prevent and control the transmission of infectious agents. In particular, IPs shall: assess the needs of customers and develop educational objectives and strategies to meet those needs; use learning principles appropriate to the target audience; use appropriate information technology in educational design and delivery; collaborate in the development and delivery of educational programs and/or tools that relate to infection prevention, control, and epidemiology; evaluate the effectiveness of educational programs and learner outcomes; and enhance the visibility of healthcare providers and their knowledge of specific infection prevention and control practices, targets, and organizational goals."
HAI surveillance allows the evaluation of the local burden of HAI and AMR and contribute to the early detection of HAI and new patterns of AMR, including the identification of clusters and outbreaks. As Storr, et al. (2017) observe, "IPC activities should respond to the actual needs of the healthcare facility, based on the local HAI situation and compliance with IPC practices. For these reasons, surveillance systems for HAI, including AMR patterns, are an essential component of both national and facility IPC programs. National IPC surveillance systems also feed in to general public health capacity building and the strengthening of essential public health functions." At the acute-care facility level, the WHO guideline recommends that institution-based HAI surveillance should be performed to guide IPC interventions and detect outbreaks, including AMR surveillance, with timely feedback of results to healthcare workers and stakeholders and through national networks."
The SENIC project found that four components of “highly effective” infection prevention surveillance programs were: (1) surveillance with feedback to health care workers, an intense infection control program including best practices with sterilization, disinfection, asepsis and handling of medical devices, an infection prevention nurse to supervise the program, and a physician epidemiologist or microbiologist with special skill in infection prevention. The challenge with surveillance is the time investment required of infection preventionists. A 2015 study presented at the 42nd Annual Conference of the Association for Professionals in Infection Control and Epidemiology (APIC) revealed 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. Many IPs, especially those in community hospitals, feel burdened by the time necessary to comply with the Centers for Medicare & Medicaid Services (CMS) reporting requirements—so much so that one IP decided to find out just how much time it takes. The answer: five hours and eight minutes a day of IP time, based on a five-day work week. That leaves little time to observe practices, go on rounds, lead safety drills, or answer questions about how to keep patients safe. IPs at Robert Wood Johnson University Hospital Somerset tabulated the amount of time necessary to review lab data and complete reports for bloodstream infections, urinary tract infections, surgical site infections, MRSA infections, and Clostridium difficile infections to the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN). IPs at hospitals across the country are responsible for analyzing lab reports and reporting infection data to the NHSN database, which is used for Medicare payment determination by CMS.
“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. “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.”
Multi-modal strategies are becoming a significant weapon in the IP's arsenal, and over the past decade, studies in IPC and implementation research have demonstrated that best practice interventions are most effective when applying several interventions/approaches integrated in a multi-modal strategy. At its core, a multimodal implementation strategy supports the translation of evidence and guideline recommendations into practice within health care with a view to changing healthcare worker behavior. As Storr, et al. (2017) explains, "A multi-modal strategy consists of several elements or components (three or more - usually five) implemented in an integrated manner. It includes tools, such as bundles and checklists, developed by multidisciplinary teams that take into account local conditions. The five most common components include: system change (improving equipment availability and infrastructure at the point of care) to facilitate best practice; education and training of healthcare workers and key stakeholders (e.g. managers and hospital administrators); monitoring of practices, processes, and outcomes and providing timely feedback; improved communication (e.g. reminders in the workplace or videos); and culture change by fostering a safety climate."
The WHO guideline emphasizes that highly functioning IPC programs should encompass monitoring/auditing of IPC practices and feedback: "IPC interventions require the consistent practice of preventive procedures, such as hand hygiene, respiratory hygiene, use of surgical antimicrobial prophylaxis, the aseptic manipulation of invasive devices, and many others. The appropriateness with which these procedures are performed depends on the individual healthcare worker’s behavior and the availability of the appropriate resources and infrastructures. To identify deviations from requirements and to improve performance and compliance, the frequent assessment of working practices is necessary by using standardized auditing, indicator monitoring, and feedback. The monitoring and evaluation of national programs is important to track the effectiveness of national policies and strategies, including providing critical information to support implementation and future development and improvement."
A 2013 AJIC study found that IPs are confident about which practices have weak or strong evidence supporting their use to prevent HAIs. A research team led by Sanjay Saint, MD, MPH, of the VA Ann Arbor & University of Michigan Medical School collected survey responses from infection prevention personnel at 478 U.S. hospitals to determine the perceived strength of evidence behind 28 of the most common hospital infection prevention practices. The following practices were perceived by 90 percent or more of the respondents as having strong evidence to support their use: alcohol-based hand rub, aseptic urinary catheter insertion, chlorhexidine for antisepsis prior to central venous catheter insertion, maximum sterile barriers during central venous catheter insertion, avoiding the femoral site for central venous catheter insertion, and semi-recumbent positioning of patients on ventilators. Conversely, practices with the weakest perceived evidence were routine central catheter changes, using silver-coated endotracheal tubes for ventilator-associated pneumonia (VAP), nitrofurazone-releasing urinary catheters, and the use antimicrobials in the urinary catheter drainage bag. According to Saint, “the perceived strength of evidence among infection prevention personnel across the country generally tracked with the actual strength of the evidence for various practices that have been reported in evidence-based guidelines.”
Regarding implementation science, Bubb, et al. (2016) remind us, "IPs use scientific studies to promote and integrate evidence-based practices into routine practices to improve the quality, reliability, and safety of healthcare. In particular, IPs shall: translate evidence-based practices and research findings into routine practice; involve the multidisciplinary team to ensure changes are vetted by all stakeholder groups; appropriately implement initiatives that maximize benefits and minimize barriers; develop strategies to remove implementation barriers such as workflow, space, or access to supplies.; and design process and outcome measures to promote consistency of interventions over the long-term."
Workload, staffing and bed occupancy was also addressed in the WHO guideline, which notes that "A combination of factors should be considered when determining the patient-to-bed ratio and the healthcare worker-to-patient ratio, including patient acuity, healthcare demand, and the availability of a trained workforce. These factors may interfere with providing optimal staff-to-patient ratio, which could potentially lead to increased rates of HAI and the spread of AMR." The guideline recommends that the following elements should be adhered to in order to reduce the risk of HAI and the spread of AMR: bed occupancy should not exceed the standard capacity of the facility; healthcare worker staffing levels should be adequately assigned according to patient workload.
Dhar, et al. (2016) remind us that "In the early 1970s, the CDC’s SENIC recommended that hospitals have at least one fulltime equivalent infection control professional for every 250 occupied beds. Later in the 1990s, participation in the National Nosocomial Infection Surveillance System required one infection control professional full-time equivalent for the first 100 beds and then one full-time equivalent for each additional 250 beds. In 2002, APIC initiated the DELPHI project on staffing. This project noted that staffing recommendations should consider not only the number of occupied beds, but also the scope of the program, complexity of the healthcare organization, patient characteristics, and the unique needs of the facility, and recommended a ratio of 0.8 to 1.0 IPs per 100 occupied beds … As the roles of IPs have increased in scope and complexity, the traditional ratios may not be sufficient to provide the necessary staffing needs of an institution. Alternative staffing ratios have been proposed. For example, one proposal counts one bed in the intensive care unit as the equivalent of two acute care beds, and a long-term care bed as one-half of an acute-care bed; and counts a hemodialysis facility as the equivalent of 50 acute care beds and an ambulatory clinic the equivalent of 10 acute-care beds. These adjusted calculations may capture workload more accurately and should be factored into business models when developing or expanding programs. Although not substitutes for trained preventionists, adjuncts to the infection preventionist such as electronic surveillance systems, unit-based nurse liaisons, and nurse advisors can help to facilitate the work of preventionists and should also be factored into staffing calculations and needs. Despite the obvious benefits of automated surveillance systems, in one study, only one-third of programs reported having electronic systems in place. Unfortunately, the increases in demands on infection prevention and control has not led to a proportional increase in infection control staffing, with reports indicating that only 18% of programs have received increased support after the implementation of the CMS Inpatient Prospective Payment System."
Also within the realm of IPC is the built environment, materials and equipment for IPC at the facility level. As the WHO guideline notes, "Safe effective performance in the delivery of day-to-day patient care and treatment is crucial for optimal outcomes, both for patients and health care workers’ health and safety. In an effort to promote effective and standardized clinical practice in accordance with guidelines, emphasis should be placed on optimizing the health care environment to ensure a work system that supports the effective implementation of IPC practices." The guideline also presents a good-practice statement which indicates, "Patient-care activities should be undertaken in a clean and/or hygienic environment that facilitates practices related to the prevention and control of HAI … and the availability of appropriate IPC materials and equipment." Additionally, the WHO guideline recommends that materials and equipment to perform appropriate hand hygiene should be readily available at the point of care.
What is lacking from the 2017 WHO guideline is a conversation about resourcing and making the business case for IPC. As Dhar, et al. (2016) emphasize, "Society as a whole would clearly benefit from a reduced incidence of HAIs and transmission of MDROs within health care institutions. Unfortunately, there are currently no direct reimbursement programs related to hospital-based infection prevention and control. Hospitals are required by regulatory bodies to have an IP, but the funding is often based on their administrators’ subjective discretions. Therefore, for IPs to achieve desirable goals, one critical role of hospital epidemiologists and infection preventionists is to convince administrators of the beneficial impact of investing in infection control activities, and demonstrate that these activities will ultimately lead to improved patient care and reduced hospital costs."
Dhar, et al. (2016) add, "Unfortunately, hospital administrators are faced routinely with demands to reduce costs and are subjected to continuous inspection and monitoring of their financial expenses and balances. Because IPs are typically categorized as cost centers and not as revenue generators, they are often identified as potential areas for budget cuts. In fact, many infection control programs have faced downsizing in recent years. This downsizing has occurred during a period where the roles and responsibilities of hospital epidemiologists have continuously and rapidly increased. Apart from traditional infection control activities, programs and infection preventionists often have responsibilities related to antimicrobial stewardship programs, patient safety, employee health, and emergency preparedness. The best way for infection control programs to obtain adequate funding from hospital leadership is to construct a business case and to assess and demonstrate the cost effectiveness of an IPP or intervention. The business case for infection control should incorporate all the various components of the institutional infection control program."
The Society for Healthcare Epidemiology of America (SHEA) provides guidance regarding constructing a business case for infection control that can assist IPs and hospital epidemiologists in justifying and expanding their programs. The SHEA guidelines outline a nine-step approach for completing a business case analysis, so that all crucial components can be assessed and included. Some key components include identifying the right audience and key stakeholders to support and approve a business proposal and to meet with key leaders and administrators early in the process, and to get feedback and input to help effectively frame the business case before a formal presentation. Whenever possible, the infection control team should seek input and support from business and financial leaders in the organization.
As Dhar, et al. (2016) point out, "It is important to make an honest assessment of the infection control situation at your institution. Most hospital epidemiologists and infection preventionists want to increase the resources available for infection control activities, but it is important to avoid overestimating potential benefits and the rapidity with which benefits might be achieved or underestimating staff costs and efforts required for success. Overestimation of efficacy in an initial analysis may provide resources in the short term, but will undermine efforts and necessary trust for success in the long term." They add, "In the era of limited resources, IPs and initiatives are subject to continuous threats and budget reductions. Hospital epidemiologists should be familiar with the basics involved with preparing a business case and try to establish relationships with financial experts and administrators who can provide advice and assist in business case preparation. Although most infection control professionals do not have formal economic or business training, fiscal analysis and responsibility has become a critical part of hospital epidemiology. The role of effective business plans and cost justifications will continue to grow in importance for infection control programs. Despite limitations, the medical literature provides economic data that can assist the hospital epidemiologist and infection preventionists in constructing a business plan for establishing and maintaining an infection control program."
Programs aside, what about the individual? In 2012, APIC addressed the individual practitioner's ability to face the demands of the future by introducing a model for IP competency. The model outlines the skills needed to advance the infection prevention field and was created to help direct the IP’s professional development at all career stages. Represented as a circular diagram with patient safety in the center, the model illustrates four critical areas of expertise that are needed for the expanding IP role – including leadership and program management; performance improvement and implementation science; infection prevention and control; and technical expertise.
ubb, et al. (2016) acknowledges the complexity of the IP role: "The field of IPC has grown over time from a primary focus on surveillance and reporting to complex program and project management, including the use of performance improvement methodologies and multidisciplinary collaboration. IPs are also responsible for the execution of comprehensive, multisystem surveillance plans; reporting to regulatory agencies; and providing expert guidance on the maintenance of healthcare environments that are safe for patients, visitors, and staff. These priorities often compete for resources. The use of technology to assist IPs in their day-to-day responsibilities may afford a level of data analysis that illuminates prevention and patient safety opportunities. One example of this is the ability to overlay coding, admission, and discharge data over HAI data to reach conclusions about higher-risk populations as well as drive prioritization and design of more effective infection prevention efforts."
The individual is required to "assume responsibility for the development, evaluation, and improvement of his/her own practice to maintain the required skills and knowledge," according to Bubb, et al. (2016), who add, "this includes establishing professional goals and objectives at least yearly; completing a competency self-assessment with a professional development plan at least yearly; seeking constructive feedback from superiors, mentors, and colleagues regarding professional practice; maintaining current knowledge through the review of best practices, evidence-based research, consensus, and guidelines; actively participating in professional organizations, both nationally and locally, if possible; and demonstrating professionalism through commitment to patient safety and protecting patients and providers by advocating safe practices and policies."
Bubb TN, Billings C, Berriel-Cass D, Bridges W, Caffery L, Cox J and Rodriguez M. APIC professional and practice standards. Am J Infect Control. 2016. Accessed at: http://www.apic.org/Resource_/TinyMceFileManager/PDC/PPS.pdf
Dhar S, Cook E, Oden M and Kaye KS. Building a Successful Infection Prevention Program: Key Components, Processes, and Economics. Infect Dis Clin N Am 30 (2016) 567–589. 2016.
Storr J, et al. Core components for effective infection prevention and control programs: new WHO evidence-based recommendations. Antimicrobial Resistance & Infection Control. 2017;6:6