The Future of Infection Prevention

Drug-resistant methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile outbreaks pandemic influenza threats mandatory reporting requirements making the business case for infection prevention and control these are but a few of the concerns on the minds of todays infection control practitioners (ICPs) as we enter 2007. In this article we explore some of these key challenges, and share the thoughts of ICPs across the country.

The role and responsibilities of ICPs are evolving to respond to the aforementioned infectious threats. In the past decade, the field of infection control has mirrored the myriad changes taking place in the U.S. public health and infection prevention agenda.

The field has grown as increasing responsibilities have been added to the infection prevention and control professionals role over the past 10 years, says Linda Greene, RN, MPS, CIC, infection control manager for Via Health Rochester General Hospital in Rochester, N.Y. Active involvement in emergency management, bioterrorism, increasing involvement in construction and renovation projects, and pandemic influenza planning are only some of these activities. At the same time, emergence and reemergence of infectious diseases, public attention to infections and infection rates, and integration of infection control activities into the overall hospital safety and quality program present unique challenges. As more emphasis is placed on infection prevention, there will be greater demands on the ICPs time and expertise.

I actually began working as a new ICP in 1994, and one of the major changes I have noticed has been the number of guidelines and documents that have been developed or revised that address areas directly affecting infection control and prevention, observes Susan Dolan, RN, MS, CIC, hospital epidemiologist for the Childrens Hospital in Denver. The challenge for me has been the ability to be able to thoroughly review each document and incorporate all the necessary changes in a way that is useful and so that the processes that are put into place are well understood and consistently followed by staff. I am also intrigued by the increased number of references that are utilized in preparing these documents which helps to facilitate the process of recommending evidence-based practice. Much of this literature is based on published works of ICPs and their teams, which signifies the importance of publishing our experiences so that we can advance the field.

Linda Spaulding, RN, C, CIC, owner of Florida- based consulting firm InCo and Associates, notes, Infection control has gone through so many changes in the past 10 years its hard to decide where to start. We used to just think about how to do surveillance and be sure that each infection met the Centers for Disease Control and Prevention (CDC) criteria for an infection or the criteria the hospital decided to use. Then things began to really change when the Occupational Safety and Health Administration (OSHA) entered the infection arena in 1992 with the bloodborne pathogen standards and then the TB standards. The implementation of the OSHA standards was a real challenge for many ICPs and to some extent continues to be a challenge. The more ICPs interpreting a certain standard, the more interpretations you get some correct and some incorrect. For some ICPs, the lack of resources and/or training has led to misinterpretation of the guideline, leading to either over-implementation and in some cases, under-implementation. Some ICPs have been given the job with no training and are expected to be experts. Facilities must understand that the better the training, the better the product.

The field has changed dramatically in the past 10 to 15 years, agrees Gail Bennett, RN, MSN, CIC, executive director of Georgia-based consulting firm ICP Associates, LLC. But the area I consider to have had the greatest impact is the evolution of the Internet. We take it for granted today but I entered infection control in 1977 when we had to struggle to get any information on infection control and the authority was the CDC. They were very helpful to ICPs but we had to request that they send us white papers on specific subjects and they would mail them to us. If we needed research studies, we did a MedLine search in the hospital library and waited for the results to come by mail. We could not get information in just minutes as we do today. Today, almost every knowledge resource that we need relating to infection control can be accessed in minutes sitting at our desks. I am still in awe of that technology and it has dramatically changed my profession.

Even as ICPs build their Internet skills, they are spending more time researching the evolving biological threats. Theres threat of bioterrorism, natural disasters, pandemic influenza, increased drug-resistant organisms the list goes on and on, Spaulding says. The skill level and knowledge base for the ICP has increased greatly and it is difficult to keep up with everything. With decreased hospital reimbursement and budget cuts its difficult for ICPs to get funding for resources they absolutely need, let alone funding for conferences. If it wasnt for the ability to access the Internet it would be difficult, if not impossible, for ICPs to do their jobs. And there are still some ICPs who do not have Internet access, so for them the job can be even more overwhelming.

While the list of challenges faced by ICPs is long, these specialists zero in on a few areas of concern. First, I think the advancement of technology is a challenge because it not only allows for the advancement of medicine and patient care but it also results in having patients with higher acuity as well as complex devices and procedures that pose a variety of infection control risks, Dolan says. Second, the emergence of drug-resistant organisms in both the healthcare setting and the community is another ongoing challenge. Lastly, balancing the day to day, actual real-time infection control issues with the time-consuming, complex processes of planning for the potential for pandemics. The infection prevention and control profession can best be described as a system-wide approach to zero-tolerance of infections, covering all aspects of healthcare. The ICP is a preventionist, charged with educating staff and patients on the importance of issues such as proper hand hygiene, new organisms and the effects of proper cleansing and use of products. In the future, it is the hope that ICPs will implement their knowledge of surveillance technology. At present, APIC is developing a template which will provide ICPs the opportunity to calculate costs of particular healthcare-associated infections in order to make a stronger case for the implementation of surveillance technology. Once completed, the template will enable ICPs to demonstrate to their administration the need for such resources.

Dolan continues, Overall, it can be said that in the future, cultures and attitudes toward infection prevention and control must change. The task of reducing infections and eliminating transmission must be perceived as a system, rather than a specific program. Herein lies the challenge of getting a tops-down and bottomsup approach to implementing infection prevention into every aspect of healthcare.

For Bennett, a significant challenge for infection control today is working with legislative bodies to format public reporting of infections in a manner that will be useful to consumers and acceptable to healthcare systems. She continues, If the legislators will listen to the wisdom that has been acquired especially at CDC with the NHSN program and use that model as more states require public reporting, we can have a good system.

Alhough complicated and multi-factorial, I think misuse and over-use of antibiotics is a key issue, states Beth Young, RN, BSN, CIC, infection control coordinator at Robinson Memorial Hospital in Ravenna, Ohio. Infection control measures to prevent multi-drug resistant organisms (MDROs) and Clostridium difficile-associated diarrhea cannot be successful without addressing antibiotic use. Greene echoes that sentiment: The most important challenges are management and control of MDROs, increasing prevalence and virulence of diseases such as C.diff., and increasing regulatory standards including issues such as mandatory reporting.

Spaulding acknowledges that keeping up to date on all possible infectious threats can be exhausting. There are so many guidelines and regulations, from departments of health, OSHA, JCAHO, CMS everyone wants what is good for the patient but the ICP becomes a paper pusher, developing policies and procedures and education programs and inputting core measure data but who then has the time to talk to patients or track staff practices? Staff turnover and multigenerational and multicultural employees limit the ability of the ICP to do a good job. Many hospitals still have only one ICP, no matter the hospital size, and many hospitals also have outpatient clinics, dialysis units, transplant units, and hospices that the ICP must cover. Spaulding continues, Many hospitals are currently participating in grant funding which gives hospitals money for purchasing personal protective equipment, staff training, laboratory equipment, etc. for bioterrorism. Doing the paperwork for the funding and tracking the money can be very time-consuming, not to mention developing the education programs and implementing staff training in areas such as decontamination training.

The key then, is acquiring and developing the skills sets necessary to juggle such conflicting and demanding workloads.

The skill sets that seem necessary to meet future infection control challenges are the ability to continually develop a knowledge base about the technology that is continually being introduced into the healthcare arena and to be able to determine the real infection control risks to your patient population, Dolan suggests. Another important skill set is the ability to prioritize using evidence and creativity. Spaulding emphasizes that flexibility is an important asset, and adds. ICPs must get basic infection control practices under their belts and be able to identify when more training is needed. Learning must be ongoing. There must be the motivation to sometimes read outside of work or attend conferences on their own dime. Become very friendly with the Internet and learn where the best information sites are. Networking is very important, as ICPs need to be part of their local APIC chapters and participate in the national APIC conferences. The ICP has to be able to roll with the constant changes that are happening every day in the world of infection control.

Bennett advises, ICPs must possess skills in several areas, including management, communication, and organizational skills. Historically we have not felt that we have adequate resources for the job therefore organizational skills are imperative for us to get the work done. In addition, management and communication skills are required for us to get our message to the decision-makers so important changes can be made as needed.

ICPs will need a combination of excellent organizational, interpersonal and problem solving skills, Greene emphasizes. At the same time they will need to be experts in data management. They will need to be able to understand and utilize quality improvement data, research data, and administrative and financial data. They will have to develop communication and presentation skills, and apply them effectively based upon the audience. Young comments, For me, its all about using the computer to sort, analyze, trend, and display data. We need more integrated systems to save us time so that we can work on prevention and control interventions and education.

When it comes to the needs of infection control programs these days, many ICPs are not shy about communicating their wish lists. The biggest shortcoming in the world of infection prevention programs are staffing, lack of education opportunities for some ICPs, and lack of strong antibiotic restrictions in some hospital formularies, Spaulding asserts. A few years ago APIC conducted a research study looking at how many ICPs are needed related to hospital size but there is no regulatory body that encourages increased staffing. With decreased hospital reimbursement, educational opportunities will remain a problem. And as for antibiotic overuse, pharmacy directors do review hospital formularies but many physicians still order antibiotics under what if scenarios. Strong physician advocates are still needed to get other physicians to change their antibiotic prescribing habits.

Recently, there was a commercial on TV featuring a penguin telling audience members if they come down with the flu they need an antiviral, not antibiotics. I think we will begin seeing more public education done this way because it gets more peoples attention.

For some ICPs, its a matter of ongoing engagement in the field. Bennett notes, I think we still have to work hard to achieve compliance with our policies, standards, and national recommendations. ICPs have a large task of constantly monitoring and being alert to changes in our field, updating policies and practices based on evidence, and assuring that the revised policies and practices are understood and implemented correctly.

Being able to communicate the value of infection prevention programs to other hospital stakeholders is key to addressing these issues, many ICPs say. Many of todays infection control programs are lacking in resources both human and technological, Greene states. Infection control and prevention programs are also undervalued by many top executives. In order to address these needs, ICPs must increase their visibility and value at the executive level. Making the business case for infection control, incorporating activities into the overall organizations strategic mission and vision, and working with key stakeholders including the community are important steps in addressing these issues.

A significant concern being brought to the attention of hospital administration these days is staffing. I think ICPs have spoken loud and clear for some time now that staffing is a key issue for their programs, Dolan says. It is mainly due to budgetary restrictions in an institution that then can result in cuts to the program or denial of additional positions and resources. I wish I had the magic answer but that would be totally unrealistic.

Staffing, staffing, staffing, emphasizes Young. I think that most infection control programs are understaffed. We could start to address this by meeting the recommendation of the 2005 Delphi Project Update on Infection Control Staffing which recommends 1.2 to 1.5 ICPs per 100 beds.

Another challenge is reconciling potentially conflicting information from regulatory or accrediting bodies. Greene observes, Although the Joint Commissions agenda for change is attempting to resolve many problems, there are often discrepancies among individual surveyors interpretation of standards. Anecdotally, many ICPs report that surveyors put too much emphasis on issues that are not evidenced-based and fail to look at the larger, more important infection control issues. ICPs need to play a more active role in developing partnerships with all stakeholders, including accrediting and regulatory agencies. Basic infection control practices such as hand hygiene or care of invasive devices often are not consistent. These issues will require us to design processes which make it easier to do the right thing, building in such things as redundancy, standardization, decision aids, and reminders.

Dolan agrees, remarking, Conflicts occur when recommendations are published that are not evidence-based. Subsequently, other organizations adopt these recommendations and they can even become regulations that ICPs are required to implement. The implementation of such regulations can be time-consuming and costly, and deter from issues that need more attention. It is important to evaluate the evidence behind recommendations and determine if one can adequately justify implementation of such practices. The difficulty is that some people look at a recommendation, trust the source of the recommendation, and therefore deduce that it must be needed. We must continue to address agencies that product recommendations that are not evidence-based, work to provide them with rationale for the negative impact of their actions, and suggest strategies to better address the issue. As a new member of the APIC Mandatory Reporting Task Force (which is a subcommittee of the Public Policy Committee), I am continually learning about important strategies that the national APIC organization is actively using to address such concerns so that ICPs can focus on what they need to be focusing on. Dolan continues, On a smaller scale, ICPs should become knowledgeable about issues in their institution and help to squelch those sacred cows that have become a part of the facilitys culture. The process to change requires strategy, evidence-based information and patience to change the system.

Looking to the future, ICPs sense that whats old is new again. I see more threats of bioterrorism and a possible attack in the United States; worse yet, I do think there will be a pandemic of some sort if not from the bird flu, then by some strain of influenza, Spaulding predicts. However, I think many ICPs are ready to handle any infection control-related issue -- some better than others depending on how long they have been doing infection control. But Im not sure everyone is prepared to handle the psychological component and the number of lives that will be lost. Most of the population today has never dealt with the number of deaths that can result from either a terrorist attack or a pandemic, and fear can cloud anyones judgment. Education and practice drills with staff can help in these situations but the general public needs education as well. Many will not understand what to do to protect themselves, some will deny that anything is happening, while others will blame the government how does any ICP plan for that?

Bennett says she admits to remaining concerned about pandemic influenza: Our current healthcare and social systems have never lived through anything quite like we will experience with the pandemic. We have to give priority to preparation for the pandemic yet many people look at pandemic influenza as a possibility but not a probability. Therefore some communities are not taking it as seriously as we have to. I believe ICPs are taking the challenge seriously but we have to get the leaders to follow our lead if we are the major voice calling for rapid action.

Greene acknowledges the challenges such as these but takes an optimistic view of the future of infection prevention and control: I see the next five to 10 years as being exciting times for ICPs. We will become agents for change, and noted for our expertise. Our opinions will be sought by leaders in our organization, and some ICPs will rise to important leadership positions within our organizations. We will have higher standards for entry into our profession and will standardize our initial education and training. We will see an increase in collaborative activities as we work together to keep infections to an irreducible minimum. Most ICPs will be ready to face the challenge, and those who are not will most likely leave the discipline.

Issues such as mandatory reporting of infections may very well prove to be the watershed point in an ICPs career, acknowledges Dolan, who adds, A main concern is that each state seems be working independently when a national approach is what is really necessary. If one of the purposes of disclosing information to consumers is to provide them with information to help them make better choices and be more knowledgeable about their providers, then we need to be able to have state to state comparisons that are accurate and have meaning. ICPs are going to need to become knowledgeable about the legislative process and work to support reputable national recommendations for disclosure of useful information to the public.

I see increasing concerns about multi-drug resistant organisms and decreasing public tolerance for hospital acquired infections, Young predicts. With leadership and guidance from APIC, the CDC, and SHEA, I think we can rise to the challenge.

Bennett adds, Our profession is full of strong, knowledgeable infection control leaders who are committed to continuous improvement in infection prevention and control. We have many champions that have accepted the rigorous task of fighting for positive outcomes for our patients. The tasks can be difficult but the rewards are great in positive patient outcomes and in professional satisfaction.