J. Hudson Garrett Jr., PhD, MSN, MPH: “I think the role of the infection preventionist has always been of the most critical importance. Every time we have an outbreak or, now, a pandemic, it highlights that further.”
J. Hudson Garrett Jr., PhD, MSN, MPH, has been keeping a list and checking it probably more than twice. Garrett has been in the thick of the battle against coronavirus disease 2019 (COVID-19) in his capacity as an assistant professor of medicine in the Division of Infectious Diseases at the University of Louisville School of Medicine. He lists what he thinks healthcare workers and the entire healthcare system needs to do to not only better battle COVID-19, but any other nasty pathogenic surprises that may be thrown our way. His list:
In the interview below, these items are numbered and in bold. Garrett says that the healthcare system needs to keep the “momentum moving forward and that we continue to be at the forefront of the great work that infection preventionists do every single day.”
Infection Control Today®: You’re going to give us your list of the top 10 things that healthcare workers and the entire healthcare system need to do to improve how we deal not only with COVID-19 but with any future pandemic, as well. Is it the order of most important to least important or does the order matter?
J. Hudson Garrett Jr., PhD, MSN, MPH: I think they sort of fall in line with each other, but number one, I think is absolutely the most important. And that’s really to  build a sustainable respiratory protection program. What we’re looking for here is to make sure every single healthcare worker, regardless of where they work, has access to a sustainable respiratory protection system. Right now, if you think of three different tiers, essentially, we’ve got tier one is where most healthcare facilities are functioning, which is that disposable N95 respirator. We all know the challenges we’ve had with supply chains with that. Tier two is one that I think is becoming more and more relevant, given the learnings that we’ve had from COVID-19. And that’s really that reusable elastomeric respirator. We’re seeing this recommendation in the CDC guidelines as well. And for myself, this is actually what I wear the majority of the time. It’s a sustainable solution. You can disinfect it. It comes with discs that you can change out that give you that continuous respiratory protection and it can be allocated by individual healthcare provider. So, rather than having to reuse masks that were not designed to be reused, such as the N95, we can have a lot safer solution. And really that last tier in this first recommendation, is there may be individuals that may fail fit testing for all of tier one and tier two. And so, we need to look at things like a PAPR [powered air purifying respirator] as an alternative.
ICT®:OK Number two.
Garrett: Number two is actually building a little bit upon that, and it’s looking at a  personal pandemic plan. One of the things that has struck me through this—and my sister-in-law, for example, contracted COVID. She works in a healthcare facility and you know, that was an area of concern for her was what does she need to do for her family? Given that she has a young child at home. And having sort of a family preparedness plan, understanding your living situation? For example, if you know the dad gets exposed and has to quarantine, how do you do that in a two-bedroom house with a child? Right? These are all things that we want to think about. And then also self-ranking our pre-existing conditions that we might have as healthcare providers. Things like morbid obesity or if you’re diabetic, or if you have chronic kidney disease, or if you have COPD or emphysema. These are all avenues that we have to be worried about and ensure that we have a plan for.
ICT®: Do you want me to keep asking for numbers or do you just want to go through it? Number three?
Garrett: Yep. Number three is really  establishing a do-it-yourself disinfection program. And what I’m referring to here is that there’s essentially sort of three different tiers of disinfection. There’s that ready-to-use product that’s widely available, those sprays and they’re wipes that are out of the box ready to use and disinfect. We’re finding that there are a lot of supply chain issues in that arena. And what many people have moved to is things like sprays that were ready to use or ready-to-use liquids. And that third scenario, which is where we have been in the past and hopefully will be emerging from, is that concentrated market where we’re actually diluting down specific disinfectants. That’s one avenue to consider. But we also want to make sure that we’re compliant with the current CDC recommendations, as well as the use of an EPA registered hospital grade disinfectant that’s on EPA’s List N. And that list, if you’re not familiar, is products that are deemed effective against novel coronaviruses. So that’s tip number three. Tip number four is one that I think we need to focus on even more, which is  cover your eyes. If I’m putting on any type of respiratory protection in the form of a mask, that means I’m worried about the mucosal membranes actually being exposed. And so, we want to ensure that we’re covering all of those mucosal membranes, including our eyes. For me, my personal preference is the reusable face shield. It gives me a lot more comfort. It’s certainly a lot more tolerable to wear the entire day. And they’re pretty readily accessible right now. But again, we want to make sure that we get to a reusable market as much as possible to assign people those PPE pieces of equipment so that they can have them. In that way, we can ensure clinical continuity of care. So that really is tip number four. Tip number five is a little bit outside of the box. And it’s really  incentivizing the team to do the right thing every single time. We’ve heard so much in healthcare about just culture and non-punitive accountability, and really that executive leadership. But we also need to look at this situation that has been presented with the pandemic and say, “What have we done well, and what have we not done so well? And how do we learn from that?” And specifically, at that frontline staff level, come to us with concerns. Make sure if there’s an issue that we address it immediately. One of the biggest areas that’s come from the COVID-19 pandemic is how do we deal with people that are calling out sick or want to call out sick or need to call out sick? And how do we compensate them so that we’re incentivizing them to do the right thing versus coming to work sick. And so that’s always an area that we’re looking to, to improve upon. Tip number six is really a step next in the right direction about personalizing your PPE plan. We know that the CDC put out a very informative poster that said that preferred PPE for COVID-19 versus acceptable PPE. And the only difference is the use of a surgical mask versus a respirator. And so, in that preferred sort of mechanism, we’re talking about the N95 or higher respirator as what we would ideally like to see when caring for these types of patients. But we recognize that supply chain issues have created backlogs. And so, the use of a surgical mask or whatever alternative we can find, combined with respiratory protection, preferably a face shield, is going to be important. And the good news is that CDC put out what I thought was a great calculator that’s called the  CDC burn rate calculator. The purpose of this calculator is to help healthcare facilities, either inpatient or outpatient, actually calculate their usage of PPE over a specific duration of time. And this is helpful. It helps us order the right supplies. That way we’re not stockpiling things that we don’t need. We also can know what our limitations are. So, for example, it may not make any sense for long-term care facilities to take care of these patients in the future. We may not have the PPE necessary. We may not have the infrastructure necessary. And so, these are all things that are being sort of analyze in this analysis. Tip number seven should be zero surprise to any of us in infection control. And it’s really building upon  100% hand hygiene compliance. We know that if we keep our hands clean, we keep our mucosal barriers covered and we disinfect surfaces, that we’re going to stop not just COVID, but we’re going to stop a lot of other pathogens out there through this more solutions-based approach. And one of the challenges with hand hygiene that has come up is the availability of commercial product. And so we’ve seen a lot of distilleries and other private partners step up to the plate which is very helpful, but we need to also ensure that the products that we’re using are safe The FDA just recently over the last 30 days has recalled over 75 different hand hygiene products due to issues with formulation and even methanol poison in some instances, as well. Tip number eight is really building upon the concept of a  hierarchy of controls. Right, this hierarchy of controls, if you were to visualize it is sort of an upside-down triangle. And at the very bottom of that are the things that are least effective in stopping transmission. That includes PPE, yet we’ve had so much of a focus on PPE and healthcare, that we need to rethink this. At the very top of that hierarchy of controls is elimination, where we’re physically removing the hazard. And we’ve seen a lot of hybrid approaches, things like the use of plexiglass or isolating people from the hazard, and that’s a form of an engineering control. And so, these are all things that we have to consider as it relates to not only patient protection, but also for workplace protection. Tip number nine is what I refer to as  the three Ps: people, process, product—in that order. We want to have the most properly trained personnel that are cross-trained, ideally. If we learned one thing through this COVID-19 pandemic, we need to make sure that we have people that are diverse in their skill set that can float back and forth. We may need a nurse to function more like a respiratory therapist or a tech to step up and actually do more advanced care when legally permitted. Having that role-specific competency is helpful. As it relates to process, we have to hardwire our basic infection control practices. We need to think about what it’s going to be like to intubate a patient wearing a PAPR. We need to think about what it’s like to give a patient a nebulizer treatment, where we’re concerned about aerosols. And then lastly, is that product perspective having sustainable supply chain so that we can maintain our operation. That’s been a huge, huge miss for us as a healthcare system is that we’ve had to shut down and actually stop a lot of these healthcare delivery services simply because we did not have PPE, or we didn’t have the resources to staff them. And tip number 10 on my last tip is really  making decisions based on true data, independent data. So, for example, if I have patients that are coming in who are asking to know if they’re immune to COVID-19, I can do serology tests, sure. I can look for the presence of antibodies. Sure. But I don’t know if that confers any type of immunity. The recent data that’s come out as recently as in early September is looking at about four months of antibody presence in the bloodstream when we actually look for it. But again, we don’t know what that antibody protection really means as it relates to conference of immunity. So that is my top 10 list that I think will help us get to a different place within healthcare, but more importantly, give us a semblance of safety for ourselves. If there’s something that scared people the most as a healthcare community, it’s really going to work knowing that you may not have the best protection. And I think we can do better. We must do better. And we can through these 10 tips.
ICT®: Any final words for infection preventionists?
Garrett: I think the role of the infection preventionist has always been of the most critical importance. Every time we have an outbreak or, now, a pandemic, it highlights that further. My only thing is I think we need to make sure we keep that momentum moving forward and that we continue to be at the forefront of the great work that infection preventionists do every single day. But also create many IPs across all of healthcare, where we have people that are champions and ambassadors on behalf of the infection preventionists. Because you may have one or two infection preventionists for a large hospital, but you may have thousands of employees that can actually become an infection prevention champion. And as Walmart always used to say, safety is everyone’s responsibility. And I think that we can adapt that same philosophy of every single associate in healthcare is an infection preventionist, maybe not by title, but absolutely by responsibility.
This interview has been edited for clarity and length.