A Conversation With Kevin Kavanagh, MD: Infection Preventionists Are Underutilized and Underappreciated

Kevin Kavanagh, MD, is the founder and board chairman of Health Watch USAsm, a not-for-profit patient advocacy and healthcare policy research organization. Health Watch USAsm is a member of the National Quality Forum and has been designated as a “Community Leader” for Value-Driven Healthcare by the US Department of Health and Human Services. He served on the Centers for Medicaid and Medicare Services’ Hospital-Acquired Condition (HAC) Reduction Program Technical Expert Panel (TEP) from 2014 to 2019; the AHRQ Standing Working Group for Quality Indicators from 2016 to 2017; and the AHRQ Health Care Effectiveness and Outcomes Research (HEOR) Study Section. He has also served on the National Quality Forum’s Consensus Standards Approval Committee (CSAC). 
Infection Control Today spoke with Kavanagh about the current state of infection control and the infection prevention industry. 

Infection Control Today: How important are infection preventionists to the workings of infection control in hospitals?

Kavanagh: Infection preventionists are of utmost importance. Just in the last year we have seen a widespread acknowledgement that carbapenem-resistant Enterobacteriaceae (CRE) has become endemic, and the fungi Candida auris has emerged as a dangerous pathogen.¹ Both of these pathogens can become totally resistant to antimicrobial agents; being a fungus, growth of C. auris can even be promoted by antibiotics. It will take complex- and situation-specific interventions to stop many of these pathogens. For example, Candida auris may not be susceptible²to quaternary ammonia-based antiseptics and it’s very hard to contain its spread. Well-trained environmental cleaning services are crucial. Alcohol is also not an effective hand hygiene agent for Clostridioides difficile, the flu virus, and the norovirus. Thus, hospital-wide training and monitoring of pathogens by infection preventionists is of utmost importance. 

ICT: Do you think that most hospitals utilize infection preventionists properly?
Kavanagh: Many hospitals do not even have a full-time preventionist. Many rural hospitals have only a part-time individual with limited resources. In a recent article by Bartles, et al,³current infection preventionist staffing needs to be 31% to 66% above current benchmarks. The progression of the epidemic of antibiotic-resistant organisms necessitates more, not less, staff. This is even more crucial in nursing homes where, according to the [US Centers for Disease Control and Prevention (CDC)], carriage of antibiotic-resistant organisms⁴ in some facilities is greater than 50%. 

Unfortunately, the vast majority of nursing homes lack both the guidance and staff expertise to confront this epidemic. Currently, a large portion of an infection preventionist’s time is devoted to record keeping and reporting of pathogens.⁴ But having comprehensive real-time data to track resistance is crucial to formulate effective strategies. At this year’s Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria (PACCARB) meetings, a number of speakers were asked questions and their answers were that we are not tracking this or the data are not available. Data are needed to prioritize the development of antibiotics and evaluate strategies to prevent spread. The answer is the hiring and training of more preventionists, a “costly” intervention but I’m afraid only a small portion of what will be needed to stop this epidemic. 

ICT: How are infection preventionists trained, for the most part? Would you like to see changes in how they’re trained and/or credentialed? 

Kavanagh: Training of infection control preventionists (ICP) may vary considerably in different states and locations. As a patient advocacy organization, we feel that all frontline healthcare workers should undergo a standardized certification process, especially in a field as complex as infectious disease. But certification standards are minimum standards that everyone is expected to meet. Competency in your facility may go far above these. For example, take hand hygiene. Compliance in too many facilities is dismal. At 100% compliance, recent research⁵ looking at glove and gown acquisitions of methicillin-resistant Staphylococcus aureus (MRSA) indicates that gloves alone stop almost two-thirds of MRSA acquisitions, making hand hygiene a cornerstone of infection control. However, two-thirds control may not be adequate to prevent spread, and in the case of drug-resistant dangerous pathogens, hand hygiene should be viewed as a backup measure, since these pathogens should not be on a healthcare worker’s hands in the first place. 

Currently, an increasing number of employers are encouraging ICPs to obtain certification. The most common is the Certification in Infection Prevention and Control (CIC), which is supported by Infection Prevention and Control Canada (IPAC), the Association for Professionals in Infection Control and Epidemiology (APIC), and the International Federation of Infection Control (IFIC). 

A recent survey of infection professionals and healthcare managers conducted by Marx, et al.⁶ reported that “certification demonstrated professional competency, increased career growth, improved regulatory compliance, was important in influencing legislation, and improved the practice of infection prevention and control.” Of more than 4000 respondents (12.6% response rate), approximately half were CIC certified, demonstrating the growing acceptance of this certification. 

ICT: How do you weigh the goal of infection prevention against the costs of trying to do so? Does it become too costly at some point? 

Kavanagh: Antibiotic resistance is on the verge of becoming a global catastrophe, impacting many facility services such as transplantation and chemotherapy. Even patients undergoing elective surgery or having a disease such as diabetes are at an increased risk [of contracting an antibiotic-resistant infection]. The argument that these organisms primarily affect the sick and frail is shortsighted, since most of us age and will fall into this category. The CDC estimates (at a minimum) that 35,000 individuals die each year from resistant organisms with another 12,800 patients dying from C. difficile. This does not count the longterm disability many of the survivors will endure. The United Kingdom’s May 2016 Wellcome Trust report estimated⁷ that by 2050 antibiotic resistance will have a cumulative cost to the world of $100 trillion dollars and 10 million lives will be lost each year. Whatever the cost, we must bear it or risk closing facilities, [cutting] services, and shortening the human life span. I fear the concerns over the cost of hiring additional nursing staff may pale in comparison to the true cost to each facility, which may be millions of dollars per year in lost revenues and additional resources needed to control this epidemic. 

ICT: According to the Joint Commission and even the CDC, it appears the crucial members of any antibiotic stewardship team are a physician and pharmacist who specialize in infection control. Where does that leave infection preventionists in the hierarchy of such teams? Are they in charge? Should they be? 

Kavanagh: Infection preventionists should definitely be part of a team for antibiotic stewardship. A true culture of safety gives weight to all team members and avoids a hierarchy top-down structure. Infection preventionists are frontline workers who are in an excellent position to intercept unnecessary antibiotic usage and to educate patients on appropriate antibiotic usage. They also are better able to observe trends in over prescribing and personally educate the involved individuals. All too often physicians cite patient pressure as a driving force behind unnecessary prescriptions. 

ICT: Do you think environmental services departments are properly integrated into the infection control process?
Kavanagh: As pointed out in a September 2015 Infection Control Today article,⁸ in the hospitality industry, it takes 30 to 35 minutes to clean a hotel room. In hospitals, the time allotted is often much less. Since this article was published, the situation has only gotten worse. Too many facilities have discharge room cleaning times below the 40 to 45 minutes recommended in the Association for Healthcare Environment (AHE) guidelines. Dependence on fogging units and copper surfaces to lessen the need for environmental services and shorten room turnover time is ill advised. These interventions can be a valuable supplement, especially in rooms occupied by patients carrying dangerous pathogens. But it must be remembered that their effectiveness lessens with biofilms or thick droplet debris. Because copper is expensive, it has been recommended for high-contact areas. However, not all copper alloys have the same efficacy and knowing the contact time used to determine the bactericidal effect is crucial. Many alloys require hours to be effective on certain organisms, making primary dependence of this modality in high-contact areas unwise.⁹ Environmental control services need to be revamped. This is a highly technical and important function of a hospital. Some are suggesting certification with varying levels of expertise, with the highest levels for units such as the Intensive Care Units and operating room. Hospitals must invest significantly in trained environmental services, which can integrate with infectious disease services and modify their protocols depending upon the patient care setting and type of pathogen. CDC is currently formulating core strategies for the implementation of existing guidance. Hopefully this will result in cleaner and therefore safer patient care environments. 

ICT: Do you see infection preventionists as the liaison between environmental services and hospital administrators? Should that be a part of their job? If so, how best to perform it? If not, why not? 

Kavanagh: There needs to be a team approach for infection control. Both positions are becoming more complex and I predict will undergo an evolution into highly recognized professions. Sometimes it takes an act of Congress to move an administration in a new direction. Having multiple voices from different professions approaching administrative personnel in unison will increase the chances of success. 

References:

1. Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States. CDC website. https://www.cdc.gov/drugresistance/biggest-threats.html. Published 2019. Accessed December 2019.

2. Centers of Disease Control and Prevention. Infection prevention and control for Candida auris. CDC website. https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html. Published December 2018. Accessed December 2019.

3. Bartles R, Dickson A, Babade O. A systematic approach to quantifying infection prevention staffing and coverage needs. Am J Infect Control. 2018 May;46(5):487-491. doi: 10.1016/j.ajic.2017.11.006. Epub 2018 Jan 4.

4. McKinnell JA, Singh RD, Miller LG, et al. The SHIELD Orange County Project: Multidrug-resistant organism prevalence in 21 nursing homes and long-term acute care facilities in Southern California. Clin Infect Dis. 2019 Oct 15;69(9):1566-1573. doi: 10.1093/cid/ciz119.

5.     Roghmann MC, Johnson JK, Sorkin JD, et al. Transmission of Methicillin-Resistant Staphylococcus aureus (MRSA) to healthcare worker gowns and gloves during care of nursing home residents. Infect Control Hosp Epidemiol. 2015 Sep;36(9):1050-7. doi: 10.1017/ice.2015.119. Epub 2015 May 26.

6.     Marx JF, Callery S, Boukidjian R. Value of certification in infection prevention and control. Am J Infect Control. 2019 Oct;47(10):1265-1269. doi: 10.1016/j.ajic.2019.04.169. Epub 2019 May 23.

7.     Review on Antimicrobial Resistance. Tackling drug-resistant infections globally: final report and recommendations. Wellcome Trust. HM Government. https://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf. Published May 2016. Accessed December 2019.

8.     Pyrek K. Room turnover times: 'Trash-and-dash' approach jeopardizes patient outcomes. Infection Control Today. 9-17-17. ICT website. https://www.infectioncontroltoday.com/environmental-hygiene/room-turnover-times-trash-and-dash-approach-jeopardizes-patient-outcomes. Accessed December 2019.

9.     Różańska A, Chmielarczyk A, Romaniszyn D, et al. Antimicrobial properties of selected copper alloys on staphylococcus aureus and Escherichia coli in different simulations of environmental conditions: with vs. without organic contamination. Int J Environ Res Public Health. 2017 Jul 20;14(7). pii: E813. doi: 10.3390/ijerph14070813.