Focus on 4 Foundations of Patient Safety

Preventing HAIs

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Health care–associated infections (HAIs) and other health care–associated conditions are among the prevailing threats to patient safety. To combat the threats, infection prevention (IP) professionals’ common goal is to be patient safety champions. One of the Association for Professionals in Infection Control and Epidemiology’s (APIC) strategic goals is to “demonstrate and support effective infection prevention and control as a key component of patient safety.”¹ In short, IP professionals work tirelessly to ensure the safety, health, and well-being of all.

Not surprisingly, the field of IP is well-practiced in promoting patient safety. In 1976, the CDC published the landmark SENIC project (Study on the Efficacy of Nosocomial Infection Control).² The findings demonstrated a 32% reduction in HAIs in hospitals with established IP programs compared with an 18% increase in hospitals without such programs over a 7-year period.² Following the publication of SENIC, tremendous strides were made in HAI prevention. However, there is still progress to be made.

In May 2018, the Institute for Healthcare Improvement (IHI) convened the National Steering Committee for Patient Safety (NSC), a collaboration among 27 US organizations dedicated to health care that is safe, reliable, and free from harm. The NSC published Safer Together: A National Action Plan to Advance Patient Safety,³ a plan that emphasizes driving improvement in 4 foundational areas of patient safety: culture, leadership, and governance; patient and family engagement; workforce safety; and learning system. These areas are already, in many respects, hardwired into the fabric of IP programs. The following paragraphs delve into some of the ways IP activities are already exemplified in the NSC plan, and how the plan can be a road map for IP professionals to expand their patient safety role.

Culture, Leadership, and Governance

In a complex environment such as health care, diversity is a strength. IP programs are composed of professionals from diverse educational backgrounds. Key personnel include infection preventionists who operate in close collaboration with physicians serving as health care epidemiologists who are often, but not always, trained in infectious diseases. In a recent survey of 4079 APIC-affiliated infection preventionists, 82.0% reported a background in nursing, 9.9% a background in laboratory science, (eg, medical technologists, microbiologists, laboratory researchers), 4.7% a background in public health, and 3.3% reported another background.4 The diverse educational backgrounds represented in IP programs permit subject matter expertise in a multitude of areas critical for program success. Diversity is also a tremendous asset in engaging with the multidisciplinary clinical teams that intersect with initiatives to reduce HAIs.

In the same survey of APIC-affiliated infection preventionists, respondents reported spending an average of 12.2% of their effort on management/communication.⁴ Although the current state of health care governance gives IP professionals a seat at the table, ongoing work is needed to ensure this seat is consistent and valued. In addition, because diverse teams are best suited to solving complex problems, IP programs should continue to recruit professionals from a variety of backgrounds and prioritize the diversity that other stakeholders bring to key partnerships. Along the same lines, IP programs should value collaboration across health care settings. Medical care operates on a continuum and includes care settings devoted to acute care to everything from ambulatory to residential care. HAI reduction measures and strategies in most health care organizations are focused on acute hospital setting practices. As many health care delivery systems implement measures to shift care toward a more accessible outpatient care system, it is imperative to educate and train to evidence-based IP practices and recruit more IP personnel in outpatient settings. Patient safety threats in one setting often have ripples in other settings, and interconnectedness across independent health care systems or public health entities adds another layer of complexity.^4-6 Finally, the recent global health disruptions related to infectious pathogens serve as a reminder that IP programs should maintain awareness of emerging and reemerging pathogens and should work to preserve networks that are dedicated to ensuring that the health care infrastructure is prepared to safely care for high-consequence pathogens.⁷

Patient and Family Engagement

As patient safety advocates, IP professionals frequently interact—directly and indirectly—with patients and families. This interaction may take several forms. IP professionals can educate patients and families on hand hygiene, respiratory etiquette, and other fundamental strategies for IP. Sometimes this education is even more tailored: for example, in the setting of a novel pathogen or medical device for which specific IP recommendations exist. IP professionals are often in a position to assess and influence patient and family experiences across the care continuum.

Several opportunities exist for IP programs to prioritize patient and family engagement. Evidence suggests that greater awareness of HAIs is needed.⁸ IP programs could meet this need by enhancing education about HAIs on the local level and also serving as sources of clarification about the implications of publicly reported measures, including HAI incidence. Additionally, there is emerging evidence that racial and ethnic disparities exist in how patients experience health care, including the incidence of HAIs.⁹ By better characterizing these disparities, IP professionals can take steps so that safe care is truly safe care for all. Finally, IP professionals should stay mindful that stigma is a powerful force in shaping the way infectious diseases are transmitted. They must work to ensure that strategies that intend to limit transmission of infectious pathogens do not perpetuate the stigma experienced by patients who are (or are perceived to be) at risk for those pathogens.

Workforce Safety

IP professionals and occupational health professionals enjoy longstanding partnerships because prevention of infection in patients leads to fewer exposure risks for health care workers. In clinical care, IP programs advocate patient vaccination as a key tool for primary prevention. Additionally, IP professionals educate clinicians on the clinical and diagnostic work-up of patient conditions that may pose a transmission so that these conditions are recognized early. IP professionals maintain expertise in the environment of health care and promote the hierarchy of controls to minimize hazards to patients and health care workers.

More recently, and especially during the COVID-19 pandemic, the importance of health care worker wellness has become an additional area of focus for health care systems. IP professionals can enhance their promotion of workforce safety by promoting total worker health (TWH).⁷ TWH promotes interventions that collectively address worker safety, health, and well-being.

Learning System

Key responsibilities of IP programs include finding cases of infections in health care settings, compiling infection-related data, and analyzing data to characterize HAIs. IP professionals continually adjust their methods of HAI surveillance to keep pace with a dynamic clinical care environment that is defined by rapid technologic advances. IP professionals have a sophisticated understanding of how HAI data convey gaps that could result in preventable HAIs. This understanding arises not only from detailed knowledge of what HAI data measure, but also from the conversations IP professionals hold with their colleagues about how HAI data intersect with the experience of clinicians. In the cycle of quality improvement efforts, IP professionals continually measure the expected and observed impact of HAI reduction strategies. HAI prevention hinges on successful adherence to best practices over the long haul, and longitudinal surveillance by IP programs reminds clinicians and administrators not to let down their guard. By the same token, highlighting success stories with HAI data is one of the many ways that IP professionals preserve engagement among other clinicians in IP programs.¹⁰ IP professionals should continually seek a better understanding of how surveillance data can be leveraged to elucidate the mechanisms underlying health care-associated infections, whether those infections are due to endogenous or exogenous flora. Understanding the mechanisms that drive HAIs may permit better understanding of the extent to which HAI “preventability” exists on a spectrum, which will in turn assist with framing interventions as capturing low- vs high-hanging fruit. In addition, microbial genomics is a powerful tool that, when combined with standard epidemiology, is poised to assist IP professionals in gaining a better understanding of pathogen transmission in health care settings.¹¹

IP professionals are veterans in preventing patient harm. An effort that aims to prevent harm can be regarded as a difficult entity to quantify, and this can have implications in health care economic landscapes that prioritize the quantification of services. However, it is important to stress that the assurance of safe care, although challenging to quantify, is truly a priceless commodity for the patients served by health care systems.

References:

1. Landers T, Davis J, Crist K, Malik C. APIC MegaSurvey: methodology and overview. Am J Infect Control. 2017;45(6):584-588. doi:10.1016/j.ajic.2016.12.012

2. Haley RW, Culver DH, White JW, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol. 1985;121(2):182-205. doi:10.1093/oxfordjournals.aje.a113990

3. Safer Together: A National Action Plan to Advance Patient Safety. 2022. Accessed Jan 18, 2023. https://www.ihi.org/Engage/Initiatives/National-Steering-Committee-Patient-Safety/Pages/National-Action-Plan-to-Advance-Patient-Safety.aspx

4. Reese SM, Gilmartin HM. Infection prevention workforce: potential benefits to educational diversity. Am J Infect Control. 2017;45(6):603-606. doi:10.1016/j.ajic.2017.03.029

5. Ray MJ, Lin MY, Weinstein RA, Trick WE. Spread of carbapenem-resistant enterobacteriaceae among Illinois health care facilities: the role of patient sharing. Clin Infect Dis. 2016;63(7):889-893. doi:10.1093/cid/ciw461

6. Simmering JE, Polgreen LA, Campbell DR, Cavanaugh JE, Polgreen PM. Hospital transfer network structure as a risk factor for Clostridium difficile Infection. Infect Control Hosp Epidemiol. 2015;36(9):1031-1037. doi:10.1017/ice.2015.130

7. Division of high-consequence pathogens and pathology. CDC. Accessed January 18, 2023. https://www.cdc.gov/ncezid/dhcpp/index.html

8. Abbate R, Di Giuseppe G, Marinelli P, Angelillo IF, Collaborative Working Group. Patients’ knowledge, attitudes, and behavior toward hospital-associated infections in Italy. Am J Infect Control. 2008;36(1):39-47. doi:10.1016/j.ajic.2007.01.006

9. Bakullari A, Metersky ML, Wang Y, et al. Racial and ethnic disparities in healthcare-associated infections in the United States, 2009-2011. Infect Control Hosp Epidemiol. 2014;35(suppl 3):S10-S16. doi:10.1086/677827

10. Gaughan AA, Walker DM, DePuccio MJ, MacEwan SR, McAlearney AS. Rewarding and recognizing frontline staff for success in infection prevention. Am J Infect Control. 2021;49(1):123-125. doi:10.1016/j.ajic.2020.06.208

11. Sundermann AJ, Chen J, Kumar P, et al. Whole-genome sequencing surveillance and machine learning of the electronic health record for enhanced health care outbreak detection. Clin Infect Dis. 2022;75(3):476-482. doi:10.1093/cid/ciab946