Many health care organizations believe diversity is the strength of their institution. Organizations are engaged in addressing inequities, reducing disparities, and increasing opportunities for diversity, equity, and inclusion to strengthen their connection to the populations within their communities.

By law, organizations have policies relating to no tolerance of discrimination in race, religion, nationality, culture, age, sexual orientation and identity, or veteran status. Health care institutions realize that diversity of caregivers improves care of patient populations. Diversity is just 1 variable that contributes to positive patient outcomes. When there is an organizational priority for inclusion, then employees have a sense of belonging and thus will contribute to increased positive patient outcomes.

Having programs emphasizing inclusion that teach and support cultural competence to appropriately act in response to people of diverse backgrounds enhances the feeling of being respected and valued. As a reminder, inclusion is the act of affording everyone equal access to opportunities and resources. Acts to promote inclusiveness in institutions aim to make the workplace safe and respectful.

Diversity, equity, and inclusion (DEI) initiatives have been a recent focus for organizations to support all employees and patients. In health care, DEI will make a greater impact as it affects patient outcomes, quality, and safety. Likewise, students in higher education, who will soon be joining the workforce, have been taught to embrace and foster diversity and strive for equity and inclusion. They have been educated on social determinants of health and the importance of working for social and institutional changes. They are eager to make a difference and will soon become our colleagues. Will we be ready to support them and help them thrive?

Infection preventionists (IPs) need to increase equity by ensuring that health care workers have the materials needed to educate the communities served. Health equity means that every member of the community has an opportunity to experience positive health outcomes. IPs need to assist the community to remove obstacles to health. Social determinants of health such as poverty, lack of education and affordable housing, and violence in communities contribute to poor health outcomes. Many communities often lack resources to promote health. Patients deserve to have educational materials that effectively provide information on evidence-based practice to reduce the risk of poor outcomes. For IPs to improve health care outcomes, an understanding of how diversity relates to all stakeholders is needed. IPs need to review diversity information and relate that information to staff, patients, and other community members. There is a need to make sure councils and task forces are diverse.

Diversity in work groups can only increase the quality and safety because varied perspectives generally lead to better results. In Healthy People 2030,1 that goal was expanded even further: to achieve health equity, eliminate disparities, and improve the health of all groups. Designing educational materials that are culturally appropriate for diverse populations is imperative. Employing effective strategies to uncover unconscious bias so educational materials are free of stereotypical assumptions is a requisite.

IPs need to create inclusive programs and services that benefit diverse and minority populations. Educational materials need to be designed to assist people with disabilities (physical, hearing, mental, social, emotional, and learning) as well as people belonging to the protective groups of race, religion, nationality, culture, age, sexual orientation and identity, or veteran status. Removing physical barriers and providing aids and services for those who need them will increase access to services.

Educational programs must also be considered for multigenerational learners. The generations include the traditionalist, the baby boomers, Gen X, millennials (Gen Y), and Gen Z.2 In general, each generation has increasing reliance on technology for learning so education will need to be provided in many formats in a variety of literacy levels. It is important to utilize different modalities to prepare educational materials, as not everyone has the same level of expertise using technology.When working with many generations, it’s important to be aware of implicit bias, a term that describes an unconscious process in which a person’s beliefs and attitudes affect his or her opinions, actions, views, and judgments.

Because of this lack of insight into bias, the individual is unaware of how their subconscious generalizations affect their decisions and behaviors when they are relating to others. The ways IPs can reduce implicit bias include focusing on seeing all people in their health education classes as individuals and reflecting on other points of view before educating groups or working with staff and populations. IPs can review course and educational materials for stereotypes and bias, such as gender, sexual orientation, and race.

Educational materials and programs need to include the social determinants of health. It is important to have policies that are patient-centered and emphasize patient rights and safety. Materials need to be written at an appropriate reading level. Many patients have difficulty with reading, writing, mathematical ability, and technology, which impedes access to and understanding of health care information.

Health education materials are recommended to be written at a fifth-grade reading level and should include pictures. Health education materials should include 1 idea per sentence. Readability is determined through various formulas that take variables such as sentence length, word familiarity, and syllables into account.

Health education presented in video and audio format will help people with visual or hearing disabilities but can also be used for individuals with low reading levels. Infographics are graphic pictures of information that tell a story and can be used to assist in communicating health education topics. Health education programs need to be affordable or free so all have access to the needed health information. Materials must be able to be translated in the native language of the patients served. When providing education to non–English-speaking patients, the appropriate use of certified competent interpreters is recommended to ensure that the patient is receiving appropriate linguistic services and the correct information is being accurately translated. Certified interpretation can be provided face to face in person, online, or via a telephone call. IPs should avoid using family members or friends to interpret.

The goals of Healthy People 2030 are to “attain healthy, thriving lives and well-being free of preventable disease, disability, injury, and premature death; eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all; create social, physical, and economic environments that promote attaining the full potential for health and well-being for all; promote healthy development, healthy behaviors, and well-being across all life stages; and engage leadership, key constituents, and the public across multiple sectors to take action and design policies that improve the health and well-being of all.”3

Healthy People initiatives need to be considered when providing health education. The COVID-19 pandemic has demonstrated the need for effective communication and development of trust with constituents served. We know DEI is critical for our health care system and the whole of society. As IPs, let’s reflect on the preventive education we are providing and the infections we are treating, but, more importantly, on those we are treating.

We need our DEI initiatives from higher education, and the health care workforce, to transfer seamlessly over to the patient side and to the community as a whole. We aim for equal access to appropriate culturally and linguistic resources, infection prevention, timely care, and comparable treatment outcomes.

We empower you all to look at your institution and the local communities. Be empowered to investigate and ask questions. If we aren’t there yet with DEI and infection control, ask yourself what you can do. Talk to your patients and the stakeholders, and really listen; this will help spark change. Your future patients will thank you.

Articles

Perspectives from a diversity of health care workers improve the care and outcomes of patients. 

Diversity Can Be Best Ally for Infection Preventionists

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in healthcare facilities today. Each column explores the Bug of the Month's etiology, the infections it can cause, the modes of transmission, and ways to fight its spread. The pathogen profiles will span bacterial, viral, fungal and parasitic species. We encourage you to use Bug of the Month as a teaching tool to help educate healthcare personnel and start a dialogue about microbiology-related imperatives.

Click here to guess the March 2022 Bug of the Month!

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in healthcare facilities today. 

Bug of the Month: Trust Me, I Pose No Threat to You at All

We’ve always said in global health and health security that it’s not a matter of if, but when. COVID-19 was no exception and yet it turned things upside down—politicization, misinformation, testing issues, supply chain challenges that left us without masks, and a sort of burned-out feeling that most of us had never felt before. Like so many in my field, I’ve spent a lifetime studying and working in pandemic preparedness, but nothing really prepares you for the realities of it.

As we work through this next phase of the pandemic and a novel variant (omicron) that has a subvariant (BA.2) that’s also stressing our systems, what have we learned? Hindsight is often 20/20 but are we at a place where we can look back and clearly discern what we’ve been through? Can we 

dispassionately examine a pandemic in which we collectively failed and learn from our experience? One could argue that our inability to learn those lessons and be able to pivot into uncertainty has been, perhaps, the most common approach to public health and infectious diseases. To be frank: We seem unable to use lessons from previous outbreaks to steer the response to current and future events. In the field of infection prevention, what does COVID-19 look like 2 years later?

One thing I’ve been grappling with was asking myself how the pandemic has changed our field. What does COVID-19 mean for the field of infection prevention and infection preventionists (IPs)? While my work in biopreparedness has focused on these events, I’m ultimately an epidemiologist and infection preventionist, meaning that I’m acutely aware of how little support there often is for future events and our work in general. What, though, does this global event mean for our field, if anything?

Infection prevention and control (IPC) often works in the shadows. We’re responsible for ensuring patient and staff safety but often with limited power or, if we have authority, it is too commonly tied to hospital administrators whose support for our work can ebb and flow. For the field of IPC, COVID-19 has certainly changed things. I look at 2 main indicators for this change: our administrative support, but also the work that’s part of the program.

First, when COVID-19 started to hit in late 2019, other health care professionals leaned on IPs. Working hand in hand with infectious disease physicians, the IPC program was the go-to source for all the latest guidance and translating it to real-world application. Hospital administrators, for the most part, leaned into the IPC program to help decipher guidance from health agencies such as the Centers for Disease Control and Prevention, liaise with local public health resources, and ensure staff were trained on the latest protocols. In a matter of days, our departments were the resource for it all…and, meanwhile, the work IPs usually do still needed to get done.

Increasing risks for central line–associated bloodstream infections for those COVID-19 patients was very real, as was the risk for other health care–associated infections (HAIs) for those long hospital stays.

While hospital leadership started to lean on IPC more, especially as guidance changed and the nuance of a novel disease became increasingly apparent in a world of misinformation, the inherent nature of the IPC program changed.

Pandemic preparedness has always been a part of IPC work, so much so that there is a chapter in a guide published by the Association for Professionals in Infection Control and Epidemiology (APIC) to help us train for 

. Suddenly, the program of IPC became intrinsically linked to COVID-19 and the pandemic response that was, on far too many days, chaotic.

IPC programs were responsible for preparing hospitals and health care facilities for the existing problems while predicting those coming down the pike, all in addition to the work that many IPs found exhausting even before the pandemic struck.

In this situation, though, IPC programs couldn’t suddenly increase staffing because it was a geographically isolated event, but this global event meant that moving forward, we would have to ensure a strong infusion of pandemic preparedness and response into IPC programs and the role of the IP.

The IP role is easily one of the most underacknowledged and underappreciated in health care and especially in this pandemic, despite how IPs came through in those first months. First and foremost, health care and ancillary support deserve more attention, support, and acknowledgement and COVID-19 has shed light on that. These are not mutually exclusive concepts, however.

We can be proud of the acknowledgement health care workers and ancillary staff such as respiratory therapists and environmental services personnel have received, while still calling for awareness and appreciation for IPC and IPs. Few articles have discussed our departments and roles, which is breathtaking considering the role we’ve had during this pandemic.

Many countries are ready to go “back to normal” and IPs are still struggling with burnout, fatigue, post-traumatic stress disorder, and a frustration that often comes with departments/roles that are seen as a cost center and not a revenue generator.

My hope, though, is that moving forward, as we saw with the Ebola outbreak in 2014 to 2016, there will be increased attention to IPC and those who are responsible for it. Our roles have changed. We have had to focus more on risk communication and combating misinformation in a time that is increasingly politicized. IPs had to become experts in re-use and extended use of masks and how to manage those programs.

We had to work with clinicians and information technology staff to ensure patients and families could talk when visitors weren’t allowed. We’ve had to navigate complex policy changes with mandated vaccines and shortening isolation periods, while still encouraging people to stay home when they’re sick. In short, I would say that our role has become ever more complex and critical and requires a deep look at the people who are able to manage something that often gets little acknowledgement.

A friend once said IPC was the “fun police” and while that made me chuckle and sad at the same time, I’ve realized that COVID-19 has shown that we’re actually one of the elements of the pandemic response that has helped keep health care afloat. We work in the shadows, the peripheral, and areas that require gray and objective review of things.

We are the future of health care. We have diverse backgrounds with expertise across many fields and the ability to pivot when needed.

That’s always been IPC, but now more than ever our roles have underscored the diversity of our work and those doing it. For the future, I hope we gain more acknowledgement and appreciation for the work we do.

I also hope we continue to see how much more we can do for public health and global health security. I hope our ability to be subject matter experts on things like disinfection, disease transmission, personal protective equipment, donning/doffing, and a million other things becomes recognized for the resource it is rather than the all-too-common focus of HAIs. The world has changed greatly in 2 years and IPC programs have changed as well. As approach year 3, the IP contribution in battling this pandemic should be appreciated more.

Saskia v. Popescu, PHD, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist. During her work as an infection preventionist, she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She holds a doctorate in biodefense from George Mason University in Fairfax, Virginia, where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in infection control and has worked in pediatric and adult acute care facilities.

As we approach year 3, the contribution made by infection preventionists in battling this pandemic needs to be appreciated more.

When COVID Turns 2: Infection Preventionists Take Stock

We will never get rid of COVID-19, but we can learn to live with it. Most experts believe it will become endemic, evolving into the sort of illness for which an individual may need a yearly vaccine, similar to treatment for influenza. Meanwhile, many people suffer 

, and since COVID-19 is a fairly recent development—it was labeled a pandemic in March 2020—experts aren’t sure what “long” means exactly. Weeks? Months? Years?

A recent study illustrated that long COVID’s physical, mental, and cognitive symptoms can cling to some patients for at least a year. The patients in the study initially had to go to intensive care units (ICUs) because of the severity of infection. The exploratory prospective multicenter cohort study was conducted in the ICUs of 11 Dutch hospitals and was 

Journal of the American Medical Association

). Investigators included 452 patients 16 years and older who survived ICU admission during the first COVID-19 surge (March 1-July 1, 2020). The patients were followed up for 1 year following their release from the ICU, and the final follow-up date was June 16, 2021. The main outcomes were physical symptoms (including frailty, fatigue, and other physical problems), mental symptoms (including anxiety, depression, and posttraumatic stress disorder), and cognitive symptoms self-reported 1 year after ICU treatment.

According to the Centers for Disease Control and Prevention (CDC), long COVID “is a range of symptoms that can last weeks or months after first being infected with the virus that causes COVID-19 or can appear weeks after infection. Long COVID can happen to anyone who has had COVID-19, even if their illness was mild or if they 

Linda Spaulding, RN-BC, CIC, CHEC, CHOP, a member of 

®’s) Editorial Advisory Board (EAB), said she’s “seen athletes in their 20s on the wait list for double lung transplants because of long COVID.” Infection preventionists (IPs) and other health care professionals on the frontlines are also in danger of contracting long COVID. “If health care workers have to give up their careers, then what comes next?” Spaulding asked, adding that the financial consequences of long COVID on the health care system could last “forever.”

As noted by Kevin Kavanagh, MD, another member of 

’s EAB, a core difficulty in society’s attempt to guide COVID-19 from pandemic to endemic is that COVID-19 is not just a respiratory virus. Kavanagh wrote in 

®’s October 2021 issue that SARS-CoV-2 is similar to HIV because it can “silently spread throughout the host’s body and attack 

 study, of the initial patient cohort, 301 (66.8%) were included in the study. The average age was 61.2 years, the average duration of ICU stay was 18 days, and 71.5% were men. A year after their release from the ICU, 74.3% of patients reported physical symptoms, 26.2% reported mental symptoms, and 16.2% reported cognitive symptoms.

The most commonly reported new physical symptoms were weakened condition (38.9%), joint stiffness (26.3%), joint pain (25.5%), muscle weakness (24.8%), and myalgia (21.3%). The respondents indicated their continued COVID-19 symptoms make it difficult to go about their day-to-day lives, with 58% of ICU survivors saying they had problems returning to work. This frequency of symptoms 1 year after recovering from severe COVID-19 disease is concerning, as much is still unknown about long COVID and the long-term health impact of COVID-19 infection.

®’s January issue, Kavanagh wrote that “much of the abandonment of public health measures has been spurred by a massive disinformation campaign, which has successfully convinced a relatively large portion of our population that, as long as one lives through COVID-19, all will be well. The young and healthy have especially embraced 

It is a false narrative, Kavanagh warns, because “the premise that mild infections do not carry significant risks is false. In part, this belief is driven by those who have not died from COVID-19 being counted as ‘recovered’ as opposed to ‘survived.’ SARS-CoV-2 causes a system infection and is commonly detected in the heart and brain, exemplified by the loss of smell from brain tissue destruction and loss of cardiac function from myocarditis. Even those who develop mild COVID-19 can develop long COVID, which, in many cases, lasts for a year or longer.”

Of course, the best way to avoid long COVID is to avoid infection by COVID-19 in the first place. IPs and other health care professionals must continue to utilize nonpharmaceutical COVID-19 mitigation efforts, such as hand hygiene, social distancing, and masking, both inside and outside the hospital. That’s one of the takeaways of a 

That study involved monitoring 2425 fully vaccinated staff at 2 referral hospitals in Tokyo and comparing their data with that of a control group. Investigators with Japan’s National Center for Global Health and Medicine (NCGM) stated that “vaccination programs alone cannot eliminate the risk of infection…. Still, we could reasonably infer that the program has contributed to the sizable reduction in the number of COVID-19 patients among the staff during the largest epidemic [up until that point].” NCGM comprises 2 hospitals that also serve as research centers that focus on infectious disease.

Despite the effectiveness of the COVID-19 vaccines, the findings bolster the argument that we cannot vaccinate our way out of the COVID-19 pandemic. “NCGM has adopted comprehensive measures against nosocomial infection since the early phase of the epidemic,” the study stated. “The current data confirm the significant role of these measures to protect health care workers against…variant infection.”

The comprehensive nonpharmaceutical anti–COVID-19 measures adopted by NCGM include avoiding what the institution refers to as the 3 Cs: crowded places, close-contact settings, and confined and enclosed spaces without wearing a mask. They also include social distancing; cough etiquette; not touching the eyes, nose, and mouth; and hand hygiene.

The health care workers did a good job of following mitigation efforts inside the hospital but not so much outside of it. The study stated “infection among the staff had occurred mainly outside the hospital [household, community, etc].” Saskia Popescu, PhD, MPH, MA, CIC, another 

® EAB member, suggests IPs should continue what they usually do, but also “focus [more] on discussing work and nonwork exposure risks and how people can be safe in both places.”

More data on long COVID will be forthcoming. On September 15, 2021, the National Institutes of Health (NIH) unveiled a $470 million study it hopes will mine data from 30,000 to 40,000 individuals who suffer 

. The effort is called the Researching COVID to Enhance Recovery 

Francis Collins, MD, PhD, NIH director, voiced some questions driving the need for answers. For instance, what causes long COVID? (The scientific name for long COVID is PASC [postacute sequalae of SARS-CoV-2]). “Is it a misfiring of the immune system that fails to reset after the infection with this coronavirus? Is it a triggering of some metabolic dysfunction? We don’t know,” Collins said.

 said long COVID symptoms exceed 4 weeks “among [individuals] who self-reported ever receiving a positive SARS-CoV-2 test result, with the prevalence of similar symptoms among [individuals] who reported always receiving a 

.” The self-reported aspect of long COVID tracking matters because medical experts, as Collins said, still do not know what it is.

Many people suffer from long COVID, and since COVID-19 is a fairly recent development experts aren’t sure what “long” means exactly. Weeks? Months? Years? A lifetime?

Long COVID Will Linger Even After the Pandemic Leaves

As the Omicron variant of COVID-19 surges to 

 in the United States in terms of infections and hospitalizations it might be easy for the public to overlook that influenza has also spiked in recent weeks. The flu spike seems to have slowed in the 

 (see chart below) according to the Centers for Disease Control and Prevention (CDC), but not enough so that infection preventionists and other health care professionals don’t have to deal with the muddle of possible coinfection. Does the patient presenting with respiratory problems have influenza or 1 of the COVID-19 variants? Perhaps it’s just the common cold or allergies?

Being able to interpret early signs of disease is vital toward taking necessary steps to recovery and mitigation—receiving laboratory or at-home test result confirmation, referring to a clinician, taking necessary treatment, and possibly isolating from at-risk persons. While limited national testing availability and stunted turnaround time has plagued the US response to COVID-19 outbreaks since March 2020, massive data collection has given experts a more refined understanding of what is early signs of COVID-19, versus possibly the flu or otherwise.

 for identifying signs and symptoms, time from exposure to infection, and duration of illness for both COVID-19 and the flu.

Signs and Symptoms of COVID-19 and Influenza

While both diseases can present asymptomatically, the respiratory viruses share about a dozen common symptoms:

Persons with the flu often feel some or all of the above symptoms—with change in or loss of smell or taste being more frequently reported among patients with COVID-19. Young children with the flu are more susceptible to diarrhea than older patients.

Relative to the common cold, these symptoms occur abruptly in infected flu patients, with the below frequency:

Separately, COVID-19 cases include signs indicating need for emergent care that may sometimes differentiate from early flu signs and symptoms, including:

Pale, gray, or blue-colored skin, lips, or nail beds

Both COVID-19 and flu can become apparent or symptomatic as soon as 1 day post-infection. However, COVID-19 symptoms have frequently presented later in patients than symptoms of the flu—a difference of 2 to 14 days versus 1 to 4 days post-infection, respectively.

However, experts have observed that the highly transmissible and dominant Omicron variant of SARS-CoV-2 has been associated with expedited time from infection to presenting symptoms, and therefore, risk of spreading disease. This further stresses the need for identifying COVID-19 versus flu cases.

Flu is often associated with a recovery time anywhere between a few days to 2 weeks, notwithstanding severe cases or development of complications including sinus infections, pneumonia, myocarditis, encephalitis, myositis, organ failure, sepsis or more. Patients with the flu are also at greater risk of secondary bacterial infections than those with COVID-19, according to the CDC.

COVID-19 illness duration, unfortunately, is an interpretation still being researched. Cases of “long COVID” have been observed to last weeks to months following infection, regardless of patients’ disease severity or symptoms. Patients additionally face risk of complications including blood clots in the veins and arteries of the lungs, heart, legs, or brain, and development of multisystem inflammatory syndrome (MIS), any of which could warrant hospitalization and continued care.

Duration of contagious flu spread can begin as early as a full day before any symptom onset, and can last from 3 to 7 days for most patients, dependent on their age and health—older patients, infants, and those with weakened immune systems may be contagious for longer than a week.

COVID-19 can be spread 2 days prior to any symptom onset, and patients remain contagious for ≥10 days after apparent symptoms and/or a positive test result, per CDC—regardless of asymptomatic status. Those with severe disease and/or weakened immune systems may be contagious for ≥20 days.

This article was originally published on 

The highly transmissible and dominant Omicron variant of COVID-19 places added pressure on infection preventionists and other clinicians to determine just what they’re dealing with. 

Flu or Omicron? Diagnosis Must be Done Quickly

Picture a busy outpatient clinic: physical therapy, oncology, cardiac, dental, urgent care. Over the course of a day, dozens of people—even amid COVID-19—may pass through its rooms: staff, patients, parents, caregivers, delivery people. In the US, outpatient visits have climbed steadily, to nearly a 

. According to the CDC’s “Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care,” the past several decades have seen a “significant shift” in health care delivery from the acute, inpatient hospital setting to a variety of outpatient and community-based settings. More than three-fourths of all operations in the US are performed in settings 

But although they have the same main players—health care providers, other staff, patients—outpatient settings are not like inpatient settings. They have unique requirements and circumstances, including those related to infection prevention and control.

Epidemiologist Joe Perz, DrPH, who works for the CDC’s Prevention and Response Branch, told 

) that “compared with inpatient care in a hospital setting or congregate care in long-term care settings like nursing homes, the outpatient environment has a ton more variety, in terms of the types of care provided. While core practices like hand hygiene and environmental cleaning apply to all patient encounters, outpatient settings also provide more specialized forms of care that come with more specialized infection control requirements. Plus, the volume of patient encounters is staggering, and this is spread across an enormous number of individually operated facilities, many of which do not have clear lines of oversight for infection control. These distinctions present significant challenges.”

If Perz had to list the top 3 of those challenges, here’s what he would choose: “Broadly speaking, I’d cite awareness, attention, and consistency. Traditionally, many outpatient settings had infection control quite low on their list of priorities and concerns. Too often it was out of sight and out of mind. Not surprisingly, knowledge of even the basics of infection control was lacking and we saw many gaps in terms of things like hand hygiene, injection safety, cleaning, and even device reprocessing. There were attention deficits and a lot of inconsistencies in terms of how outpatient providers practiced infection control.”

The result? The CDC says data similar to those for hospital-acquired infections are lacking for most outpatient settings, but “numerous outbreak reports have described transmission of gram-negative and gram-positive bacteria, mycobacteria, viruses, and parasites. In many instances, outbreaks and other adverse events were associated with breakdowns in basic infection prevention procedures.”

Case in point: In 2015, a CDC research team reviewed investigations of health care-associated infection outbreaks in Los Angeles outpatient settings between 

. Of the 28 investigations, 79% revealed more than 1 infection control breach.

Lapses in infection control were suspected as the source for 16 (57%) of the investigations, such as using single-use medications multiple times or reusing fingerstick blood glucose meters. Bacterial agents were implicated in half of the identified outbreak investigations. Breaches were frequently associated with injection safety, equipment processing and sterilization, and environmental cleaning. An investigation of a urology office, for instance, revealed that the facility had been improperly cleaning and disinfecting cystoscopes for more than 10 years.

The investigators were perturbed by their findings. “The lack of change in 5 decades related to outbreak source and infections resulting from preventable unsafe behaviors is alarming,” they wrote in their report for 

, “Most outbreaks documented could have been prevented by using standard precautions and practicing basic infection control. These findings highlight a need for more infection control oversight of outpatient settings, as well as better reporting from outpatient settings.”

That was 6 years ago. Has time made a difference? Time that has included COVID-19? Things have changed, after all. A 2020 data analysis found visits to ambulatory practices declined nearly 60% by early April 2020. Even after a rebound (across all specialties), numbers were still roughly one-third lower than 

And in a 2021 study, investigators tallied outpatient visits between January 1, 2020, and June 15, 2020, among 16,740,365 

. They found in-person visits from January 1 to June 10 dropped from 102.7 to 76.3 (a decrease of 26.4 or –30.0% change). By the last 4 weeks, the percent change from baseline ranged from –73.2% in Hawaii to –16.0% in Alaska.

No matter how few the visits, though, the basic problems remain. Kelsey OYong, MPH, CIC, supervising epidemiologist at Los Angeles County Department of Public Health and lead author on the investigation review, tells 

 that “other than COVID-19 in the past 2 years, lapses in infection control continue to be the most common source of outbreaks.”

Though this varies by outpatient setting type, says OYong, her department continues to see reuse of single-dose vials and equipment as outbreak sources. Culprits also include environmental contamination and improper cleaning and disinfection of equipment.

“In a way,” says OYong, “the COVID-19 pandemic has highlighted the importance of infection prevention generally, and specifically in the realms of respiratory hygiene, personal protective equipment, source control, and employee health. Many outpatient settings are improving infection control practices and knowledge as it relates to respiratory diseases. We hope that this knowledge translates to other diseases, spread by contact or procedures, as well.”

The ultimate goal in all this is not only good health care, but safe health care (take another look at the title of the CDC guide, however; it sets the bar for safe care with “minimum expectations”). Many vulnerable patient populations rely on “frequent and intensive use of outpatient care to maintain or improve their health,” the guide says. Each year, for instance, more than 1 million cancer patients receive outpatient chemotherapy, radiation therapy, or both. But according to CDC data, since 2002, at least 9 serious infectious disease outbreaks, including unsafe injection practices, have occurred in cancer clinics. Hundreds of patients were infected; thousands more required notification and testing for 

Obviously, building—or reinforcing—a stronger foundation for infection control would help. Compared with inpatient acute care settings, the CDC says, outpatient settings have traditionally lacked infrastructure and resources to support infection prevention and surveillance activities. And, to restate more of the obvious, outpatient settings are not like inpatient settings.

“In the broader context of all the hardships we’ve experienced, on the provider and patient sides of ambulatory care, there is greater appreciation of infection risk,” says Perz. “And we are seeing this across the spectrum, from primary care to specialized outpatient settings.” But, he adds, “to maintain effective outpatient care, there needs to be a foundation of protections, for both patients and health care workers.

OYong agrees. “The pandemic has stretched health care workers to their professional and emotional limit. For many settings, the majority of staff time is now spent on COVID-19 response efforts, taking away especially from surveillance and adherence monitoring activities. Stress and burnout are serious concerns for the health care workforce.”

They’re not only worn out; they’re also being stretched intolerably thin.“For infection preventionists in the outpatient setting,” she says, “juggling many different roles is a big challenge. They often play the role of infection preventionist, employee health director, risk manager, health educator, and health care epidemiologist, plus their normal nursing and clinical roles.”

Moreover, she points out that “sometimes designated infection preventionists [Ips] in outpatient settings don’t have the same access to resources or community that inpatient IPs have. They often work independently if they’re not part of a larger health care system or network and may not have access to community best practices or policies.”

That’s beginning to change, though, Perz says. “One very positive development I’d like to highlight is 

, CDC’s national infection control training collaborative. Project Firstline’s content is designed so that, regardless of a health care worker’s previous training or educational background, they can understand and apply the infection control principles and protocols needed to protect themselves, their facility, and their patients from all infectious disease threats, such as COVID-19.” (“The COVID-19 pandemic has underscored gaps in infection control knowledge and practice in healthcare settings nationwide,” the 

Project Firstline teams up a coalition of academic, public health, and health care partners plus 64 state, local, and territorial health departments through the Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases Cooperative Agreement. One of the initiatives integrates “enhanced infection control content” into community college classrooms. The program designers say they chose community colleges because they educate a significant portion of the US nursing and allied health care workforce; know how to meet the unique training needs of a diverse, intergenerational health care workforce; and are equipped to tailor training and educational resources to fill critical gaps in underserved communities.

While those up-and-coming health care providers are being trained, what to do about the ones with boots already on the ground? OYong has some suggestions for how to handle the persistent challenges she and the other investigators identified in 2015. For instance: Make it a group effort. The pandemic naturally changed practice. It also may have changed attitudes about “my job” vs “their job”; we’re truly all in this together.

“Building an infection prevention team helps mitigate all of those responsibilities falling to a single person,” she says. “Creating a facility-wide culture of safety helps all staff take accountability for infection control. Empowering all staff to speak up when they see issues with PPE, injection safety, etc. helps stop lapses at their source.”

Perz says “thepandemic experience taught us a lot about keeping our guards up to keep infection risks down. This begins when patients enter—or even approach—an outpatient facility. We are now all much more sensitive to the needs for things like screening, triage, and source control. We have been forced to be more mindful of the needs for worker protections, which were often taken for granted. These needs were all present prior to the pandemic but were vastly underappreciated.”

In the meantime, here’s his best evidence- and experience-based advice: “Remember that your efforts to stem the spread of infections are making a real difference. As health care providers, your mission has always been to protect health and promote quality of life. More than ever, infection control is central to this mission.”

Jan Dyer is a writer and editor specializing in clinical topics. She lives in Suffern, New York.

Outpatient settings are not like inpatient settings. They have unique requirements and circumstances, including those related to infection prevention and control.

Infection Control in Outpatient Settings: Old Challenges, New Realities

Creating change within the sterile processing (SP) profession begins with asking the right questions in order to gain a better understanding of where process improvements can best be made to benefit SP professionals, their customers, and the patients on the receiving end of the SP department’s (SPD’s) instrumentation and services.

Having served in the SP profession in various roles for many years (from frontline technician to educator and, finally, leader) I saw, felt, and experienced what it was like to work in every area of the department. When it comes to the challenging environment of decontamination, especially, and the knowledge and skills needed to ensure all employees wear personal protective equipment (PPE) effectively, safely, and consistently, I’ve made some observations over the years—namely, that properly donning (putting on) and doffing (taking off) all these layers of PPE can sometimes collide with other departmental needs and challenges, such as time and space restrictions and the ongoing and ever-evolving need for supplies, equipment, staffing, and education.

The decontamination area is the first stop in the detailed process of providing clean, properly functioning, disinfected, and sterile medical devices for patient use. At the same time, this area poses the greatest risk to the technician thanks to the potential exposure to blood-borne pathogens and other microorganisms. Additionally, there is the potential for physical injuries if SP professionals in the decontamination area are improperly or inadequately trained and equipped to deal with these challenges. Leaders must ensure that all staff SPD members not only are provided with the correct PPE but also are well trained on how to use it safely, consistently, and effectively.

Recent study data published in the December 2, 2021, issue of the 

“Droplet Dispersal in Decontamination Areas of Instrument Reprocessing Suites”—highlighted how medical device processing professionals may be exposed to tissue, blood, and patient fluids 

. These eye-opening findings suggest the need for more research to support evidence-based guidelines and instructions for safe processing, and also serve as a stark reminder that SP professionals need access to the proper equipment, training, and support to help ensure they remain as safe as possible in the workplace. As this study demonstrates, the historical experience of “doing things the same way we have always done them” is not enough. We must look beyond at the hard data and always be thinking of ways to improve in the name of quality and safety.

Many of us who have worked in the decontamination area can attest to the challenges of this environment as well as to the real and perceived risks associated with decontaminating instruments and devices used in patient care. This 

 study elevates the discussion significantly because it has provided solid scientific findings to substantiate discussions and concerns from those in the SP profession. Equally important, this first real-world study that evaluated PPE effectiveness involved collaboration between frontline SP technicians, Healthcare Sterile Processing Association (HSPA) members, and the scientific research community.

HSPA, the professional association that provides certification, education, advocacy, and support for SP professionals worldwide, is certainly taking note of these study findings and is working to remind its 40,000 members and certification holders (as well as others within the general SP community) of the critical importance of process improvement and proper PPE supplies, support, and ongoing training (HSPA was formerly known as IAHCSMM—the International Association of Healthcare Central Service Materiel Management).

Study coauthor and HSPA member Marie Brewer, CST, CRCST, CIS, CHL, CER, GTS, CSSGB, SP, manager at UnityPoint Health, St. Luke’s Hospital in Cedar Rapids, Iowa, tells 

 that “collaboration with Cori Ofstead and associates made it possible scientifically to explore and document the aerosolization risks in a real-world decontamination environment. This research is important because the data clearly demonstrated the need to redesign PPE and improve decontamination protocols to reduce blood-borne pathogen exposure risk to technicians.”

This study and the significance of its findings are already changing the dynamics of the conversation regarding the risks SP professionals face in reprocessing areas. These important discussions are opening up greater dialogue on what we know (and do not know) and why we cannot rest on our laurels when it comes to employee safety, knowledge growth, and risk mitigation. Within HSPA, these study findings and conversations strengthen our resolve to ensure that our education and training are aligned with the new scientific knowledge.

This scientific knowledge will allow the industry to develop new technologies, solve problems in practical ways, and help frontline SP professionals make better, more informed decisions. It is the successful combination of products and the adoption and application of science-based practices that will help this industry rise above these challenges and protect our frontline technicians. I am excited to know that we are at the forefront of essential scientific discovery, where data and newfound knowledge will contribute to new applications and training that will be a game changer for our profession’s future.

To best understand why solid research and collaboration are so essential to the future of our profession, we SP professionals must first understand our role in the science of what we do every day. We must embrace that we are a participant in science; our participation gives us a sense of belonging within our chosen profession—an ability to belong to something bigger than ourselves. We are participating in the future and that future is happening now. It is not about what we know (or think we know), but about how we think and apply our knowledge that is so powerful.

Science is about asking questions in the quest to objectively discover what is true. The vital research between Ofstead and Associates and HSPA members like Marie Brewer (and many others who have opened their doors for critical studies) is helping put the essential pieces together now so we as a profession can broaden our knowledge and face the next challenges with science- and data-driven insight, discipline, diligence, and vigilance.

Communication on what SP professionals do on a daily basis and the whys behind it is paramount to ensuring the highest level of safety and service quality. 

 what we want to measure is the first part; 

 what we need to do comes next. We want all SP technicians to be empowered to see and participate in change and to maintain a hunger to learn and grow for the sake of oneself, the team, the customers, and the patients. This hunger for knowledge and truth, even difficult truths, is what will help capture more attention for the discipline, spearhead more studies, research, and education, and ensure that all SP professionals receive the proper training (and provide return demonstrations of the training received) to ensure that PPE and other essential supplies, equipment, and devices are used safely and optimally.

 study has shown the critical gaps regarding PPE and practices currently in use while also underscoring the risks and challenges SP technicians face in the decontamination areas in particular. Although more work needs to be done to instill process and equipment improvements, it is essential that SP professionals know the important role they can play right now in bringing about positive change that will help keep them and their colleagues and peers safer in the workplace. The information provided in the 

 study allows us all to proactively reflect on our own practices and processes. In the near future, we will surely have more information and recommendations, but in the meantime, I encourage all SP professionals, especially those in leadership positions, to read the 

 study, ask questions within the department, and be part of the educational process regarding proper PPE use.

I believe it is every leader’s duty to deliver quality education consistently and in meaningful ways that resonate with employees. If we can help communicate and show the science and the value of our profession, then that is what we must do for the greater good. Proactive planning, practice, and open dialogue across all stakeholders will advance our profession and improve safety and outcomes for our SP technicians, health care customers, and patients.

Damien Berg, BA, BS, CRCST, AAMIF, serves as vice president of strategic affairs for the Healthcare Sterile Processing Association (formerly IAHCSMM).

The successful combination of products and the adoption and application of science-based practices will help the sterile processing profession rise above challenges to protecting frontline technicians.

Make Personal Protective Equipment Fit Sterile Processing

Demand for the knowledge that infection preventionists (IPs) possess soared when COVID-19 first struck in 2020, but by just how much might surprise even IPs who worked through those initial surges. The infection prevention and control (IPC) department at the University of Iowa Hospitals & Clinics (UIHC) experienced a 500% increase in consultation calls from January 2020 to December 2020, compared to calls received in the pre-COVID-19 period of 2018 to 2019, according to a 

. Investigators collected data from 4745 calls received by the organization’s IPC department during the COVID-19 period to the 6564 calls received during the pre-COVID-19 period.

Data were also collected in focus groups and one-on-one interviews with members of the IPC department in which they were asked to explain changes in their working conditions during the COVID-19 period.

“Our IPC program experienced a 500% increase in consultation requests,” the study concludes. “Planning for future bio-emergencies should include creative strategies to increase response capacity within IPC programs.”

UIHC, an 811-bed tertiary care center with over 200 outpatient clinics that cares for more than 36,000 patients each year, has a long tradition of infection prevention; it launched its IPC department in 1969.

When COVID-19 struck, phone consultations about SARS-CoV-2 elbowed other clinical considerations out of the way. Calls about non-COVID-19 related matters decreased substantially during the period. In the pre-COVID-19 period, the IPC department received a median of 71 calls a month. During the COVID-19 period, that increased to 368 calls a month, and about 50% of those calls concerned isolation precautions.

“Infection preventionists reported that the ambiguity and conflicting guidance during the pandemic were major challenges,” the study states.

Calls concerned the following categories:

exposures, for both health care professionals and patients

handling outside requests from public health departments or other medical centers

The IPC department also kept an eye on non-COVID-19-related problems. Changes in incidence were monitored for health care-acquired infections (HAIs) as follows:

central line-associated bloodstream infections (CLABSI) per 1000 central-line days

catheter-associated urinary tract infections (CAUTI) per 1000 catheter days

 infections (CDI) per 10,000 patient days

CLASBIs increased significantly during the COVID-19 period, to 1.8/1,000 per central line-days. CAUTIs and CDIs did not show a statistically significant increase.

Along with HAI monitoring, the IPC department also oversaw infection control data analysis, policy writing, outbreak investigation, education, and collaboration with other departments. IPC also monitored hand hygiene, social distancing, and masking.

Monitoring, though, was not foremost on the minds of those who contacted the IPC department. “While surveillance is a core responsibility of IPC programs, consuming almost 40-45% of IP time, surveillance issues represented less than 1% of IPC program calls in our study.”

As the calls increased, the IPC department went from taking calls on a 7-days-a-week schedule to 12-hour blocks of time. “This scheduling change allowed us to designate an IP to night calls, permitting the team to have rest intervals,” the study states. “Also, we established a call center and trained staff volunteers from the departments of nursing, quality improvement, and research to help answer daytime calls.”

The IPC department also created a frequently asked questions document to help with calls from the public and enlisted the UIHC integrated call center to take calls from the community. The IPC department grew from 7 to 9 fulltime IPs.

“We also began using cycle threshold (Ct) values paired with the assessment of symptoms and serology to evaluate the need for isolation precautions,” the study states. “Ct values were only available to IPC members, requiring us to be consulted when patients were positive for COVID-19 and asymptomatic.”

An alert built into the electronic medical record allowed clinical staff to take steps to evaluate the need for isolation precautions and what kind.

The study also notes that “remarkably” calls from the department of public health actually decreased by 75% during the COVD-19 period, perhaps because of allocation of public resources.

The study concludes that “in addition to supporting a proactive COVID-19 response, our IPC program experienced a substantial increase in consultation requests during the COVID-19 period. Most calls were regarding COVID-19 related issues, and we observed a decline in communication regarding non-COVID-19 issues. This may reflect less frontline emphasis on HAI prevention. As the COVID-19 pandemic transitions to endemicity, IPC programs should be strengthened by ensuring adequate staffing, compensation, and creative work modalities.”

Before COVID-19, the infection prevention department got a median of 71 calls a month. When COVID-19 struck, that rose to 368 a month, with 50% of calls concerning isolation precautions, the study states.

Infection Preventionists Swamped with Questions During COVID-19 in 2020

Before the arrival of various variants of COVID-19, such as the Delta variant, reinfection of health care professionals and first responders over a 9-month period was fairly uncommon, according to a 

. Investigators with the Centers for Disease Control and Prevention (CDC) looked at serology surveys and viral testing results of participants from Rhode Island from March 1, 2020, to February 17, 2021, and for New York City participants from March 10, 2020, to December 14, 2020. The rollout of vaccines began December 14, 2020, in both jurisdictions but vaccine data were not used in this study, and symptom data were also unavailable.

“Seropositivity decreased reinfection risk,” the study states. “Lower reinfection risk associated with exposure to a household member with COVID-19 before the serosurvey may reflect subsequently reduced household transmission among members of previously infected households.”

Included in the study were individuals who tested positive for SARS-CoV-2 14 or more days after their first serology test. The CDC investigators defined reinfection as a second positive test 90 or more days after the first positive test.

“The association between serostatus and reinfection was assessed with a proportional hazards model adjusting for demographics, exposures, and virus testing frequency,” the study states.

Of 1572 participants who’d been infected with SARS-CoV-2, 40 (2.5%) were reinfected. Reinfections for seropositive participants was 1.9%; while 8.4% of seronegative participants were reinfected. Most of the reinfections occurred among nursing home residents and corrections personnel in Rhode Island (n=30). They were also tested the most, with a mean testing rate of 30.3 tests as opposed to 4.6 for other Rhode Island and New York City participants.

The greater number of tests in Rhode Island sprung from the CDC mandating routine periodic testing for nursing home residents and staff. The Rhode Island Department of Health conducted frequent testing among prison personnel because of COVID-19 outbreaks in those institutions.

“Although increased testing frequency was mandated in New York skilled nursing facilities, nursing home personnel were not included in the New York City serosurvey,” the study states.

The adjusted hazard ratio (aHR) for reinfection in seropositive versus seronegative persons was 0.41 (95% CI 0.20, 0.81),” the study states. “Exposure to a household member with COVID-19 before the serosurvey was also protective (aHR 0.34, 95% CI 0.13, 0.89).”

Individuals who reported exposure to a household member with COVID-19 prior to the serology survey were less likely to be reinfected. Reinfection was not associated with other risk factors such as underlying health conditions.

“Studies of health care personnel have found that community transmission was a strong risk factor for initial infection,” the study states. “Persons initially infected in their households may have a lower risk of subsequent household infection if household members also developed immunity.”

articles

CDC investigators looked at what might cause reinfections during the first wave of the pandemic.

COVID-19 Reinfections in Early Stage of Pandemic Examined

The sudden appearance of the Omicron variant of COVID-19 shifted the discussion over how best to ward off infection—a discussion which had evolved over the course of the pandemic to mostly focusing on vaccines and boosters. But as Tedros Adhanom Ghebreyesus, the general director of the World Health Organization, put it during a 

 on December 14: “It’s not vaccines instead of masks. It’s not vaccines instead of distancing. It’s not vaccines instead of ventilation or hand hygiene. Do it all. Do it consistently. Do it well.”

Ah: “Do it well.” Just what does that mean when it comes to masking for the public, patients, and health care professionals? Investigators with the National Institute for Occupational Safety and Health (NIOSH), a division of the Centers for Disease Control and Prevention, say that it means having a mask that fits just right.

“Layering a 3-ply cloth mask over a medical mask (double masking) or securing a medical mask with an elastic brace provided the best source control performance,” they write in a preprint 

). (Source control means reducing the expulsion of air particles.) The study continues that “these mask fit modifications can be implemented by health care workers, patients, and the general public alike.”

3-ply medical face masks with elastic earloops and adjustable metal nose strip

2-ply polyester blend face masks with earlooops

Earloop toggles or a mask brace made for a better seal and enhanced the fit of medical masks. The mask brace “significantly improved” how cloth masks fit.

Infection Control Today, March 2022, (Vol. 26, No. 2)