By Gary Evans, Medical Writer
Infection preventionists (IPs) are playing critical roles in the coronavirus response, raising the profile of a profession that will never be viewed quite the same again after having been forged in the crucible of the worst pandemic in a century.
“IPs have been front and center through all of this and have been really embedded with the command centers [in hospitals],” says Ann Marie Pettis, RN, BSN, CIC, FAPIC, president-elect of the Association for Professionals in Infection Control and Epidemiology (APIC). “They have had to evaluate the constantly shifting recommendations from the experts such as the CDC (Centers for Disease Control and Prevention), WHO (World Health Organization), the state and county health departments. IPs have had to take an unbelievably pivotable role, and that has not been lost on the C-suite.”
Emerging research that will become more granular as the pandemic continues should provide empirical evidence that infection prevention rose to the grim occasion, blunting the impact of SARS-CoV-2 (COVID-19) as it surged and ebbed in regional outbreaks.
“Once you prove you’re valued-added, and they don’t perceive you as a cost center per se, I think that helps us make the argument for things like additional technology, which costs money,” says Pettis, director of infection prevention at the University of Rochester, NY. “I think our added value has been seen and embraced at this point, but the research will be important, and it is going on during the pandemic.”
Practice changes may be forthcoming as well, much in the same way that the first severe acute respiratory syndrome (SARS) outbreak in 2003 made respiratory hygiene or “etiquette” standard in waiting areas and emergency rooms. “That became a new normal, and we have never gone back from that,” she says. “There were lessons learned back then, and there will be lessons learned through this pandemic for all sorts of healthcare-associated infections (HAIs). There are a lot of studies coming out as we speak.”
For example, a recent study of COVID-19 in 26 skilled nursing facilities (SNFs) in Detroit found that those with more infection control consultations had about half as many positive tests as those without IPs, according to a CDC report.1 Overall, the study found that repeated point prevalence surveys (PPS) at the SNFs identified an attack rate of 44%. Within 21 days of diagnosis, 37% of infected patients were hospitalized and 24% died.
All facilities received an initial infection prevention and control (IPC) assessment, and two follow-up IPC assessments were conducted for 12 facilities participating in a second survey. The infection control interventions included reviewing cohorting practices using a facility floorplan, assessing the supply and use of personal protective equipment (PPE), hand hygiene practices, and staffing mitigation plans.
“Among facilities participating in both surveys, the percentage of new laboratory-confirmed cases declined from 35% to 18%, suggesting that facility-wide testing and on-site IPC support might have contributed to reductions in SARS-CoV-2 transmission,” according to the CDC report. “Following testing and establishment of a COVID-19 care unit, IPC assessment and consultation were critical to assisting facilities in targeting interventions to mitigate suspected causes of ongoing transmission.”
As SARS-CoV-2 tests become more available, repeated point prevalence surveys and “enhanced and expanded IPC support should be standard tools for interrupting and preventing COVID-19 outbreaks in SNFs,” according to the CDC report.
“The IPC support was composed of teams of one to three IPC-trained clinicians — [including] physicians, nurse practitioners and physician assistants — who performed on-site assessments of IPC practices and provided improvement recommendations,” says lead author Guillermo Sanchez, MSHS, MPH, a member of the CDC COVID-19 Response Team.
Although there was an overall decrease in mortality during the study, the data were insufficient to determine if infection prevention consults were the primary reason.
“The short-term implications are that repeated PPS in combination with IPC interventions appears to reduce SARS-CoV-2 transmission, and possibly contributes to improvements in morbidity and mortality,” he says. “If this is true, then it would suggest that there may be a bigger role for ongoing infection prevention and control efforts in SNFs during the COVID-19 pandemic.”
While infection prevention in post-acute settings clearly is valuable, the vast reach of the pandemic may lead to many industries seeking IP consults, Pettis says.
“I think you are going to see infection prevention and IPs moving into nonhealthcare settings, which is very exciting,” she says. “COVID has really pointed out the need for that, whether it be the travel industry, the food industry, recreation, sports, and the entertainment industry. Moving forward, I think we will see a lot more attention paid to infection prevention in those venues.”
With the pandemic pushing a high level of healthcare worker compliance with hand hygiene and other measures, the challenge will be for IPs to sustain the gain in the aftermath.
“Hand hygiene right now is kind of off the charts,” she says. “Moving forward it will only increase the level of attention not just on the [IPs], but more importantly, on infection prevention [overall].”
A tantalizing question is whether the emphasis on infection control during the pandemic will translate to reductions in HAIs that IPs have been battling for decades. In that regard, Pettis has split her staffing responsibilities so that some focus on COVID-19 and others track traditional infections, such as those caused by drug-resistant bacteria.
“Our surveillance is continuing for HAIs,” she says. “Amazingly, we really have not seen an increase. One could argue that things have been so stressful and so crazy that we would, but perhaps because people are paying so much attention to the basics of infection prevention, hand hygiene, and PPE, we really have not seen a spike. It seems to be helping.”
Vigilance is a must, as healthcare pathogens are nothing if not opportunistic. For example, Pettis became concerned after noticing that no one was using the hospital water fountains out of an abundance of caution for COVID-19. “We started worrying about biofilm building up and did a lot of water testing for Legionella,” she says. “Everything was negative — we were so relieved. We don’t want to take our eye off the ball.”
IPs have a singular opportunity to elevate the profession, but nobody is saying it will be easy. Indeed, as this report was filed, daily U.S. total cases were climbing steadily, public masking had become politicized, and any hopes that the coronavirus would be blunted by hot weather were effectively dashed.
“It has raised our visibility. It has increased our credibility,” Pettis says. “It is sort of ‘be careful what you hope for’ because it is also exhausting. Everyone in healthcare is pretty worn out. We’re not through the first wave and we are trying to prepare for the second wave.”
Same Virus, Different Vendors
Reports of shortages of PPE continue in some hard-hit areas, but a lot of manufacturers have stepped up production of critical items. As different brands and types of equipment are used to bolster stocks, it raises the question of whether staff retraining is needed in some cases. Although staying with the same vendor may be preferable, this is a luxury that IPs may not be able to afford.
“One of our challenges is with alcohol-based hand rubs,” Pettis says. “We can hardly get any of the particular one we use that fits in to our dispensers, so now we are having to look at switching things out. But then you go to another supplier, and they already have their customers, so you have to get in a queue. It is definitely still a challenge, even if you are not in the one of the states that is seeing a surge right now.”
Another example is restocking disinfectant wipes, which may have varying contact times recommended by different manufacturers. “With all the PPE, you may need to do retraining, because there are idiosyncrasies in different equipment and supplies,” she says. “This requires ongoing evaluation, particularly by IPs. We tend to be the ones that have to look at the [product], decide whether it is appropriate or not, and then reeducate the staff on how to use this PPE.”
This is a particular concern with respirators that require fit testing, says Michael Calderwood, MD, MPH, a hospital epidemiologist at Dartmouth-Hitchcock Medical Center in New Hampshire.
“N95s differ quite a bit in their shape and fit, so as we run into supply issues, hospitals may need to bring in different models of these respirators,” he says. “We could run out of one N95 [model] that people have been using for a long time and have been fit tested with. If we bring something new in, is it similar enough that we assume it has the same fit? Do we need to retest people to make sure that it fits to their face? That is always my concern.”
The choice may be one of reprocessing the respirators staff are familiar with or bringing in a new product and redoing fit testing.
“A lot of hospitals have been able to reuse respirators with the same efficacy after undergoing decontamination procedures,” he says. “You have to have in place an ability to look at how well those masks are filtering and [assess] them in terms of fit. Many of the masks come back damaged from general wear and tear, so it does require some infrastructure.”
As hospitals in some areas reopen for elective surgeries, it becomes more critical to keep track of PPE needs in case COVID-19 resurges. Calderwood’s team is using a modeling program to project coronavirus transmission, then bringing in patients who deferred care for other conditions during the pandemic.
“It really had an adverse impact on patients as they waited to get care,” he says. “They may have waited a long time for their surgery, and now they require a more complex procedure. So, people are being very careful not to do what we had to do the first time — turn everything off.”
Dartmouth has an analytics institute, which has adapted the Penn Chime model to forecast coronavirus activity for the local area out to four weeks.2
“We do our modeling and see if we have enough PPE to handle it,” Calderwood says. “We look at cases both in our healthcare system and in other hospitals in our region. If we see an increase in COVID cases — we have to turn down other activities.”
Supply Chain Reinvention
While modeling may help manage PPE, there is a general consensus that the medical supply chain must not revert to the lean inventory management systems that left facilities scrambling nationwide when the pandemic hit.
“We learned this very early on,” Calderwood says. “We had kind of standard use of PPE and had supplies to support a number of days. But of all of a sudden, we were getting into an environment where we needed a lot more PPE.”
A recent analysis of the pandemic by the MIT Center for Collective Intelligence recommended creating resilient supply chains that have both stockpiles of essential equipment and diagnostics, and the ability to ramp up production.3
“The whole just-in-time supply chain idea, I would hope has been proven to be woefully inadequate and must be addressed,” Pettis says.
APIC and many other infectious disease and public health groups have penned a letter urging the federal government to extend the current emergency declaration, which is set to expire on July 25.4
“We are not out of the woods yet,” Pettis says. “We’re very concerned about the fall, when we may see flu at the same time as the second wave of COVID. We can’t be looking back wishing we had prepared adequately. It seems true that at the local, state, and federal level — none of them were really ready with the amount of PPE that is needed. I think the idea of continuing the emergency preparations is incredibly important.”
The letter to the department of Health and Human Services urges renewal of the emergency declaration for at least an additional 90 days.
“It is imperative that the federal government continue to deploy all resources and authorities necessary to protect the public and assist states and localities as they continue to respond to this urgent situation,” the authors state. “We cannot afford to ease up on our response to this grave threat.”
With all signs suggesting the pandemic of novel coronavirus may be with us for a while, there have been various silver linings anticipated, including that infection prevention will emerge as a proven safeguard against the inevitable appearance of a future threat.
“You never want to miss an opportunity to increase your level of credibility,” Pettis says. “Every now and then there is a bright side to a crisis, even COVID.”
- Sanchez GV, Biedron C, Fink LR, et al. Initial and repeated point prevalence surveys to inform SARS-CoV-2 infection prevention in 26 skilled nursing facilities — Detroit, Michigan, March-May 2020. MMWR Morb Mortal Wkly Rep 2020;69:882-886.
- Penn Medicine. COVID-19 Hospital Impact Model for Epidemics (CHIME). https://penn-chime.phl.io/
- Kong DS. Pandemic Supermind activation: First findings. MIT Center for Collective Intelligence. https://cci.mit.edu/wp-content/uploads/2020/06/Pandemic-Supermind-Activation_First-Findings.pdf
- American Public Health Association. Letter to U.S. Department of Health & Human Services. June 23, 2020. https://www.apha.org/-/media/files/pdf/advocacy/letters/2020/200623_azar_covid19_ph_emergency.ashx?la=en&hash=FB3B1D3CF27CF7BE77431F79A4043AEB91BEA7B1