By Marilyn Hanchett, RN, MA, CIC
Editor’s Note: Marilyn Hanchett spent more than four years at the Association for Professionals in Infection Control and Epidemiology (APIC). During these years she traveled extensively and met with individuals and groups across the United States. In this issue she concludes a three-part series on issues confronting the IP profession. Her first article (July 2015) addressed internal professional challenges. The second (August 2015) focused on immediate external role pressures. In this final segment she examines future developments in science and technology that will bring sweeping changes to the IP community.
Science and technology are well recognized and important drivers of change. Likewise the escalating pace of scientific advancement in healthcare has contributed significantly, especially during the 20th century, to increased longevity and quality of life. Both acute and chronic care have improved due to the scientific discovery and new technologies designed to apply the discoveries in specific situations. The advancement of medical science has opened new practice areas for a diverse range of healthcare workers and continues to create opportunities at a never before experienced rate of change.
Infection prevention practice, less than 50 years old as a specialty (or to some, a subspecialty), has been somewhat immured from broader impact of major healthcare change. However some notable role transitions have occurred. For example, an expanded infection preventionist (IP) role was probably the first, gradual reflection of the changes occurring at a national or, at times, international level. The demand for surveillance data and the rapid rise of pubic reporting is another important response to significant national trends. Technology to support a more sophisticated and complex approach to surveillance, particularly in acute-care, has followed the expanding data demand, but is yet to realize widespread adoption in most U.S. hospitals. The volume of tasks to be performed and their associated institutional expectations have increased over time, but in its most basic aspects the IP role remains essentially unchanged in terms of core functions: surveillance and reporting, regulatory and accreditation compliance, orientation and staff education, immunization programs, and periodic rounding.
The probability of the role in its present configuration remaining viable is slim. Not only is it subject to a number of serious internal pressures, but it is concurrently struggling to cope with external threats, such as recruitment and retention, which are both immediate and far reaching. The escalating loss of registered nurses in the IP role has been recognized by constituents groups but has not been fully analyzed for it short and long range impact.
The impact of science and technology are already adding to the profession’s many challenges. No longer had a step removed from broad based healthcare change, the IP function now stands directly in the path of a science and technology whirlwind that will permanently impact the role and how it will be configured in the future.
A major advance in science, and one whose early impact can already been seen, is the shift away from culture based to genomic surveillance. Slow and sometimes variable serologic testing and in vitro analysis are being replaced by real time or rapid models based in molecular detection systems. IPs can attest to the initial phase of this promising trend as Clostridium difficile testing, that once used to include cultures, is now most reliably performed using PCR testing. PCR models continue to offer hospitals an expanding array of tests essential for reliable and rapid diagnostics. On a broader scale, molecular models have demonstrated their usefulness in outbreak and epidemic situations, including the West African Ebola virus in 2014, where these models were vital in understanding the origin and transmission of EVD in the affected countries.
As this type of science evolves, IPs will no longer need to dedicate blocks of daily time to reviewing cultures and sensitivities. In fact, the procedures used by IPs to complete these tasks for the past 40 years will eventually become obsolete or, at best, limited in their application. In their place the IP will need a deep understanding of the emerging systems and ability to both identity and respond to the variances these systems will quickly report.
Another area of science is point-of-care testing (POCT). These kits, which are designed either for use by professionals by or by patients without healthcare supervision, are already popular in fields such as blood glucose monitoring, pregnancy testing, and screening for fecal occult blood. New uses are predicted to include identification of infectious diseases, especially in under resourced areas. Smaller, more affordable and easier to use test units are expected to help increase the size of the global market to more than $27 billion by 2018. Scientific advances in POCT will contribute to significant practice changes especially for IPs working outside of hospitals and in other areas where rapid testing is essential. POCT also offers the intriguing possibility of initiating isolation and disease containment measures in different ways, and perhaps sooner, than has been possible in the past.
A third and equally important area of future science will address the human microbiome. As scientists discover more about the biome, especially gut flora, the approach to the treatment of disease will adjust. Likewise IP understanding of basic host defense mechanisms will expand exponentially, the majority of new knowledge addressing areas of microbial interaction with humans not yet known. The basic preparation of today’s IPs in biology and microbiology will be insufficient in this new science and will change dramatically in response to a different understating of complex microbial environments. New competencies will be required as more is learned about metagenomics and gene sequencing.
Science and technology are usually intertwined, and IPs can expect that all of the scientific changes previously described will support various types of new technology. But looking ahead, there is one change in technology that will have a profound impact on the IP role. That change will be information system based surveillance.
These new systems are already being developed and are based on algorithmic detection models that can be integrated into existing IT platforms. For example one group of researchers has demonstrated successful CLABSI surveillance in four U.S. hospitals using an electronic, algorithmic model. This research team suggests that three dimension of expert knowledge are required for a successful automated system: clinical, informatics and surveillance.(1)
The emergence of these electronic surveillance systems depends heavily on the use of clinical data architecture, sometimes referred to as information systems architecture. These broad terms describe the complex ways patient level information is collected, coded, stored and shared. While it may appear futuristic in scope, its basic use is already adapted to the CDC NHSN where it supports file transfer. Its use is practical yet as a distinct system component, it remains invisible to most NHSN users.
The use of electronic surveillance systems offers IPs an opportunity to envision their role in a dramatically different way. When the advances in science and technology are combined, the number of hours the IP must dedicate to daily routine surveillance activities can be expected to decrease sharply. While the exact number is unknown, these advances could easily impact five to six hours of productive daily IP time. The final impact may be even greater. Minimally, the current IP role emphasis on data collection, case reviews, application of CDC infection definitions, and report generation will be permanently altered by the impending arrival of electronic systems.
The Risk of Role Obsolescence
Given the looming changes in science and technology, the current IP role will change irrevocably. Whether or not it will become obsolete depends on how the IP community prepares for and responds to the coming changes. Obsolescence is a possibility but only one of several.
In the worst-case scenario the use of new technology and electronic surveillance systems might offer the hospital the opportunity to divide the remaining portions of the role, e.g. staff education, employee health, clinical rounding, to other existing departments without adding excessively to established workloads. The traditional IP role could be replaced with a highly trained individual who would be qualified to coordinate the program. Alternately, program coordination could be assigned to another professional role, assuming that person has the education and experience needed to satisfy oversight requirements from regulatory and accrediting bodies.
On the other hand, the elimination of time required for traditional data management tasks would make it possible for the IP position to be redesigned as an expert clinical role, perhaps drawing from the clinical nurse specialist or even a nurse practitioner model. There is widespread, albeit unstudied, consensus among IPs today that the increasing data demands of the past 10 years have removed much of the original clinical aspects of the role as it was first envisioned. Systems and technology that reverse this trend could in fact foster a much more patient centered role than is possible today.
It is also possible that an entirely new type of IP role may emerge once the aftermath of the impending changes is better understood. No matter how the future IP role may emerge, much of that future will depend on how the current challenges are addressed. The need to define the role, stipulate a basic curriculum, establish entry into practice requirements, pursue advanced education and training, as well as manage urgent issues such as recruitment and retention, will serve as the foundation upon which a unified practice community can best prepare for the sweeping changes ahead. Inability to resolve the current challenges will diminish the probability of success as the intensity and complexity of external threats increase.
The IP community is at a critical junction in its professional journey, and much depends on the choices and actions taken in the next few years. Both today’s challenges as well as tomorrow’s sweeping changes cannot be avoided. But with a collective will, a new shared vision and a renewed commitment to safe patient care, a stronger IP role can certainly emerge.
Marilyn Hanchett, RN, MA, CIC, is an infection preventionist and independent author. She may be reached at firstname.lastname@example.org.
Reference: Hota B, Lin M, Doherty JA et al. Formulation of a model for automating infection surveillance: algorithmic detection of central line associated bloodstream infection. J Am Med Inform Assoc 2010 Jan – Feb; 17 (1): 42-48.