A path to empowerment has opened: Time to move to the patient bedside
'We are only going to get this opportunity once.'
By Gary Evans, Executive Editor
Having finally wrested a seat at the C-suite table, infection preventionists are now poised to move to the patient bedside. A profession that has labored in relative obscurity for much of its existence is at a critical juncture with a host of influential agents who are suddenly very interested in infection prevention: patients, consumer advocates, state and federal regulators. A path to empowerment has opened.
"I think we are only going to get this opportunity once and we must make it truly effective," said Katrina Crist, MBA, the new Chief Executive Officer at the Association for Professionals in Infection Control and Epidemiology (APIC).
Crist had to hit the ground sprinting as she attended her first annual APIC educational conference recently in Baltimore. She sat down for an interview with Hospital Infection Control & Prevention shortly after the meeting, reflecting on her career journey and the profession she has taken the challenge to lead.
"I see the value of the infection preventionist it's enormous," she said. "You can put out the best science and I have been part of research centers. You can come up with all the concepts and ideas and validate them all you want. But if they are not implemented, frankly they are meaningless."
This challenge of implementation of translating science into day-to-day prevention with full compliance falls to the IPs and hospital epidemiologists caught up in the surging national interest in health care associated infections (HAIs). Will they rise to the occasion or be buried under the data collection demands that are part of this new normal?
"It is all about the evidence in terms of what you do at the bedside in implementing what you find in the literature to improve patient care," said Russell N. Olmsted, MPH, CIC, APIC president told conference attendees in a keynote address.
Adding a quote from Goethe, Olmsted underscored the present sense of urgency. "Knowing is not enough; we must apply," he said. "Willing is not enough; we must do."
There was much similar discussion at the APIC meeting about IPs seizing a singular opportunity, and one of the extraordinary signs of that is the association's new campaign to reach out directly to patients. An unprecedented educational campaign urges patients to arm themselves with information about HAIs and ask about the hospital's infection preventionist on admission. (See handout) This, in a field that has long suffered under what veteran health care epidemiologist Vicky Fraser, MD, once aptly described to HIC as "a psychopathology of secrecy." No need to belabor the liability concerns and other issues that led to this early culture, which included arcane and presumably protective language like "nosocomial" infections. Suffice it to say that bringing the IP to patient awareness and perhaps literally to the bedside is an idea whose time has come.
"APIC will help the professionals move closer to the bedside," Crist said. "We are educating the public in the community that infection preventionists exist within your hospitals. They have every right and we encourage them to ask to see [the IP] and get more information and take a more aggressive approach to their own care. We are also going to try and capitalize on the increased visibility and being out there in the public to get the attention of the hospital executives."
Powerful partnerships forming
A major development in this area is the recently formed Partnership for Patients, which has made HAI prevention a major priority in a collaborative that includes hospitals, patient advocates and influential federal agencies like the Centers for Medicare and Medicaid Services (CMS).
"That's really where the rubber meets the road we need to connect with our patients," said Olmsted, an epidemiologist in Infection Prevention & Control Services at St. Joseph Mercy Health System in Ann Arbor, MI. And part of that connection is a new transparency, with the traditional barriers between IPs and patients removed, he said, envisioning a scenario that may become common in the future.
"You come in on a Monday morning and get a phone call," Olmsted said. "It is a patient up in 302B who says `I think I may have an infection, can you come up so we can talk about it?' I think that is coming soon, where the infection preventionist is going to be a real-time consultant. We need a presence right at that bedside and should not be afraid to talk to our patients."
In a similar vein, health care workers who want to "do the right thing" must be supported by a culture change that recognizes infection prevention as a system problem that warrants a system solution, said Elaine Larson, PhD, professor of pharmaceutical and therapeutic Research at the Columbia University School of Nursing in New York City.
"We need to move from a perspective where your 'client' is the individual physician or nurse . Your client is the system," Larson said. "We are we now called upon much more to be leaders. We are at the table and we need a skill set [for that mission]. You have to own it."
A leading researcher on hand hygiene infection prevention's cardinal principle and enduring challenge Larson shared a personal anecdote at a packed session at the APIC conference.
"I remember when I was a nursing student working night shifts as a nursing assistant," she said. "After my first few weeks, one of the other nursing assistants said to me, "When are you taking your sick day?' I said, 'Well, I'm not sick.' She said you have to take your sick day every month because we all do, and if you don't it's really going to [make us mad]. It was a huge dilemma and I think I only stayed there three months. But if I had stayed on that unit these were professional nursing assistants that had been there a long time that's a huge amount of pressure. It's really hard even if you want to do the right thing. So we have to see the unit as our client, not individuals. It's too hard for people to fight, kick against [the prevailing culture.]"
There is no common understanding of health care delivery as a system of interdependencies, Larson said. "We all are interdependent on each other and there is no agreement on a sole focus for identifying problems and solving them," she said. "The people who provide the care are not necessarily empowered to improve how the system works. That's why I think that your clients are not the individuals who are stuck feeling like they have to take a sick day."
How can health care culture be changed so that individual workers see infection prevention as both a personal and, more importantly, an institutional goal? The answer may be in the highly successful campaigns to drive infection rates to zero, particularly the use of checklists and other measures to prevent central line associated blood stream infections (CLABSIs).
"I was trying to figure out why [these campaigns] worked because it's not really new stuff that we are asking people to do," Larson said. "This is why I think it worked: First of all, there is explicit overt support from the top down. They buy into it. The hospital 'signs up' and people feel like they are part of a movement: 'I'm part of this. I'm doing this.' Simple, clear measureable actions. Here is what we do: 1, 2, 3, 4. And clear measurable outcomes."
While working at an organization level, such campaigns give the health care worker fulfillment of such affirmations as, "I want to be a good health care professional. I want to do a good job and be proud," Larson said. "Think about the campaigns that you've read about and how they may apply as you are working on an intervention."
Indeed, IPs will need to increasingly apply social sciences and novel approaches to behavioral change if longstanding problems with compliance are to be overcome, Olmsted said. Future training should ideally include such areas as implementation science, leadership and management, communication skills, teamwork, negotiation, human factors engineering, organizational behavior and group psychology.
"That last one is going to be critical if we are going to get hand hygiene up to that 99% - 100% level, all the time, all three shifts around the clock," he said. "That is going to be a challenge for us, and we have a lot to learn from the social scientists. We need to be connecting with them as well."
Failure is not an option
Historically, it is fair to say that when it came to health care infection prevention, failure was seen as a regrettable option. But no longer are HAIs viewed as an inevitable consequence of care, though some undefined portion of them certainly must be. The default setting has shifted; HAIs are largely preventable not inevitable. The prevailing mindset in this new era of infection prevention was captured succinctly by Steve Gordon, MD, president of the Society for Healthcare Epidemiology of America (SHEA).
"Perhaps the most distinguishing feature of a highly reliable organization is their collective preoccupation with the possibility of failure," he told APIC attendees. "At the patient bedside I think what that means is every patient, every time, no exceptions, no excuses. No matter who is treating that patient, no matter who that patient is."
To achieve such a culture change, IPs and health care epidemiologists must lead infection prevention collaboratives.
"Human infallibility is impossible, so we must have collegial interactive teams," he said. "Infection preventionists embody team building as I hope health care epidemiologists do. True teamwork depends on collegiality and mutual respect. Patient safety depends an inordinate amount on our teamwork."
This new challenge calls for people with a passion for prevention, and as a massive shakeout continues in the aging health care work force there is an open question whether the demographics will meet the demand.
"The biggest threat I see is how do we continue to attract the best and the brightest into our fields?" Gordon said. "Is this a job, a career or a calling? We need to make sure that people who enter this field have that passion, whether it is nursing or on the physician side."
One answer was underscored by Gordon's presence at the podium, as observers have long called for a much more vital partnership between SHEA and APIC as part of the changing perception of HAIs. Indeed, the rapid rise of infection prevention collaboratives is among the more promising signs in the field, Olmsted notes. In particular, the aforementioned CLABSI campaigns produced rather stunning results, according to the Centers for Disease Control and Prevention.1
"We have had significant progress," Olmsted said, rallying the APIC crowd. "We've saved 27,000 lives in this process and saved probably $1.8 billion dollars in health care costs. Give yourselves a round of applause."
However, he pointed out another number that was not so positive. How many APIC members are certified in infection control and carry the CIC initials in their titles? Nineteen percent, Olmsted reported. While the figure may certainly reflect that many among APIC's thousands of members are not hospital based IPs, the lack of certification in the profession seemed to surprise the APIC audience. With the perception that the field must master new skills to take full advantage of an historic opportunity, the fact that many IPs are not proving that they know the old ones is an obvious concern.
"Certification is a commitment to personal and professional development over and above any other benefits," Olmsted said. "I would encourage you all to pursue certification. The IP is really currently at the table. There is a lot of focus on what we do we need to deliver on that."
- Centers for Disease Control and Prevention. Vital Signs: Central Line Associated Blood Stream Infections United States, 2001, 2008, and 2009. MMWR 2011;60(08):243-248
APIC's bold move to raise the IP profile
Educating public, patients about their role
The Association for Professionals in Infection Control and Epidemiology (APIC) is reaching out to the public and patients through an unprecedented educational campaign to explain the role of the infection preventionist in healthcare settings.
The campaign, "Infection Prevention and You" provides print material to help guide important conversations patients should hold with their healthcare team to prevent infection. (See handout) It is the first consumer campaign of its kind designed to educate patients about infection preventionists a growing profession of dedicated experts who partner with the broader healthcare team and implement evidence-based methods to ensure that patients, healthcare personnel, volunteers and visitors avoid healthcare-associated infections.
"Patients often feel intimidated in the healthcare setting and may not know what to say or what do to stay safe," says Ann Marie Pettis, RN, BSN, CIC APIC Communications Committee chair, who assisted in developing the campaign content. "Many also don't understand the important role infection preventionists play in patient safety. The information in this campaign helps patients understand that they can play an active role in their healthcare to prevent healthcare-associated infections and medical error. We hope hospitals and healthcare organizations will use these materials to promote quality and safety initiatives within their facilities"
Developed with input from Children's Healthcare Atlanta, the APIC campaign material is available in a variety of print and electronic formats, including posters, brochures, fliers and PowerPoint presentations for closed circuit television. Individual healthcare organizations can also customize the material by adding their logos and the contact information for their infection prevention department.
The APIC campaign material is available for free download at http://www.apic.org/patientsafety.