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 recently spoke with Kavanagh about the current state of infection control and where the industry might be going. 

ICT: How important do you think infection preventionists are 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. 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 susceptible to 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., current 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 organisms 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. 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 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 long-term disability many of the survivors will endure.
The United Kingdom’s 

 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: 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, 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.
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.

*This transcript has been edited for length and clarity.