How Veterans Affairs Handles Infection Prevention

The infection preventionist (IP) job in the Veterans Affairs (VA) health care system differs from the IP job in the private sector. Perhaps not by much, but it’s different, says Robbie Hilliard, MSN, RN, CIC, the infection prevention coordinator, at Carl Vinson V.A. Medical Center in Dublin, Georgia. One of the biggest differences is how infections are tracked, says Hilliard, who’s a member of Infection Control Today^®’s Editorial Advisory Board. “We all calculate rates based on their days of care and the number of infections that each unit has,” says Hilliard. “But we classify our patients a little bit differently.” The VA acts as a proving ground for infection prevention innovations, such as printers that can print out personal protective equipment. “A lot of these innovations are diffused from VA facility to VA facility before they ever hit the private sector,” says Hilliard. IPs in the VA system also work closely with other specialties. “And a good example of that,” says Hilliard, “is the non-ventilator associated pneumonia initiative that VA recently took on, and that was led by dental for the most part. Infection prevention benefited greatly.” In other words, an IP in the VA system has to be a Jack-of-all-trades. “We do everything,” says Hilliard. “We do ambulatory care. I do all of the outpatient clinics, just like I do the nursing home care facilities.”

Infection Control Today^®: I know that you’ve worked as an IP outside of the VA system, too. How do the two roles differ, if they differ at all?

Robbie Hilliard, MSN, RN, CIC: Infection preventionists in the private sector and in the VA—they’re very similar. Both do surveillance for health care-associated infections [HAIs]. Both monitor hand hygiene. They’re involved in antimicrobial stewardship. They’re very similar in a way. The biggest differences that I have noticed are how they track infections in the baselines. We use different baselines in the private sector than we do in the VA for each respective area. VA uses IPIC—the Inpatient Evaluation Center. And it helps us to manage and organize our data. It’s where we report our HAIs. And then IPIC turns it over to the NHSN [National Healthcare Safety Network], which is where everyone else reports there’s. I think it’s very useful. It helps us to get our ratios and all of our percentages and that kind of stuff. We can just put in the data, and it automatically gives us the information that we need. That

Robbie Hilliard, MSN, RN, CIC

helps us to calculate all our rates and do our bed days of care and that kind of thing. That’s very helpful. I also liked that the VA has a national MDRO [Multidrug-Resistant Organisms] program office. IPs in the private sector tend to have to do MDROs by themselves, and they have to do both jobs. Usually, they wear two different hats. But having a program office designates one person at this VA for multidrug-resistant organisms and that allows a single staff member to focus on those bugs that are hard to kill, that have the potential to do a lot of damage to patients, to do a lot of harm. And I also like that VA research often leads to innovative infection prevention methods. A lot of these innovations are diffused from VA facility to VA facility before they ever hit the private sector. It’s easy to sit back and let other disciplines help, I think in the VA, because those disciplines will ease the load on the infection preventionist. And a good example of that is the non-ventilator associated pneumonia initiative that VA recently took on, and that was led by dental for the most part. Infection prevention benefited greatly. But when we saw the beginning of the program, the dental [experts were] assisting to help lead the way. I think that is very helpful to us to have other disciplines, where you don’t quite see that as much in the private sector as you do in VA.

ICT^®: Do hospitals and hospital systems outside of the VA reach out to you sometimes to find out what you’re up to?

Hilliard: Yes, that happens a lot of times. We collaborate with outside facilities a lot, especially now that COVID-19 has hit. We work very closely with the epidemiologist in the local community. It’s in our area, or demographic area. We do work with them a lot. And they do reach out a lot. We receive a lot of research from facilities. In San Francisco, the universities there … there are a lot of places that would like to get our input because we serve such a large rural community. And so that’s fascinating to some people, because we don’t have transit. We don’t have a lot of the resources that other places have. But we still serve the same veterans and offer the same services. A lot of times they reach out to us to see what our best practices are for getting those services to veterans in a rural area, especially here in Georgia.

ICT^®: I’m thinking—and correct me if I’m wrong—that you serve an older demographic than do IPs in the private sector. Fair assumption?

Hilliard: Yes, we do have a lot of older veterans, but we also serve a lot of young. You’d be surprised: The age group here ranges greatly from low 20s, and our oldest patient in-house right now is 106.

ICT^®: I’m not only talking about ranges. Isn’t it fair to say that we’re talking about retired veterans who are older?

Hilliard: Yes, we do serve a lot of retired, older veterans. I just think that we’re doing more outreach as far as mental health and things. That is bringing in a younger population.

ICT^®: During the first wave of COVID-19 nursing homes were hit hard. Did you see that as well?

Hilliard: [Not really.] Because of our reporting requirements as [a federal agency]. We report a lot more than the general public. They may go in and report it to the Joint Commission. But we do a lot of different reporting and, I think, a whole lot more accountability. And when you do that, and you’re making an attempt to be transparent. I do think it brings more scrutiny and more spotlight to you. But I don’t think that our numbers were any different than anyone else’s. I think we were probably about the status quo about the same as everyone else as far as deaths in our older population for COVID-19.

ICT^®: Do you think COVID-19 changed the infection preventionist job in any way? And if so, how?

Hilliard: The job of infection preventionist didn’t change from COVID-19, but it evolved a little bit. There’s a lot more reporting these then there’s ever been. We’ve never reported the way that we report now. That has increased significantly. There’s huge need now for IP guidance in multiple disciplines. Our phones have never rung so much before. We’ve never had the email traffic that we have now. Like mental health patients. Mental health prevents COVID-19 differently than urgent care, for example. I don’t think we’ve ever had the request for our expertise quite as much as what we’ve had during COVID-19. And we continue to do the same thing we’ve always done. Stress hand hygiene, respiratory etiquette, social distancing, but we would always do that during flu season.

ICT^®: Does the infection prevention department occupy a different position in the health care hierarchy in Veterans Affairs than it does elsewhere?

Hilliard: I would probably say yes, because when a patient comes to the VA, the placement can be very unusual. For example, I’m under quality management. I’m considered quality management staff. Whereas in a hospital, you don’t really see that. You’re really more up under medical, and you work closer with medical. I think that because we have such a vast majority…. We have seven C-BOCs [Community-Based Outpatient Clinics]. Infection control for a C-BOC is very different than infection control for one of our CoCs [Continuum of Care units] like our nursing home units. And very different from our surgery unit. I think that we have such a wide variety that it takes somebody being better quality, versus just medical, because it’s not all usually about medical here. It’s about everywhere a patient is seen—that area being safe and conducive to patient care. We only have three VA [hospitals] in the state of Georgia that are medical centers. That’s Atlanta, Augusta, and us [Dublin]. That’s it. That’s health care for the veterans. If you’re a veteran who lives 50 to 75 to 100 miles away from us, the easiest thing for you to do is to go to one of our outpatient clinics, our C-BOCs. They’re freestanding clinics. They give vaccines, draw blood, do the things that meet the patient’s needs without them having to come all the way down here. And if they need to see a specialist, they’ll do telehealth. They could sit down at the C-BOC 100 miles away and confer with a pulmonologist here or a cardiologist there. Because rurally there’s just so much we can do. There’s such a wide amount of space covered here, geographically, that we just can’t cover it all with big VA [centers]. We have smaller clinics that are open to a serve our veteran population.

ICT^®: One of the concerns of the infection preventionist profession is that 40% of IPs are due to retire in the next 10 years. Is that demographic challenged faced at the VA as well?

Hilliard: Oh, absolutely. Infection preventionist is a dying breed. Usually when you go into this position, you stay in it for a long while because it takes so long to learn everything and to get certified. In the old days, you had to practice actively for two years as an IP before you could even take your certification board. They’ve waived that now and that’s to help more people get certified. There’s such a large variety of things that infection control encompasses that it’s hard to be knowledgeable and it’s hard to know everything that you need to know without just putting in the years and that’s the truth. And the only way that you’re going to get the experience is that every time something crops up that you don’t know very well you learn it very well when you face it one-on-one in your facility. I do think that that is probably an issue we do see a lot of. Another thing is it takes so long to hire in the VA system that the old infection preventionist has gone by the time new one gets there. When I came on, there was nobody that knew anything about infection prevention here. I just had some background myself, and I was flying by the seat of my pants.

ICT^®: How do you try to encourage younger people to consider infection preventionist as a career choice?

Hilliard: Well, we do have students that come all the time. We have lots of nursing students. We have pharmacy students, radiology students. And we also have people that we do practicum for our nursing population, like when nurses or go back to school to get their bachelor’s or their master’s or they’re here for their clinicals. That’s always a good opportunity. We do a presentation to them for orientation. And I try to make my presentation as interesting as possible. Because I love infection control, it fascinates me. And I try to use some of the things that fascinate me to fascinate them. To say, “Hey, look at this slide of MRSA [Methicillin-resistant Staphylococcus aureus] and look at what happens after you use some hand gel. Take a look at the difference.” And it’s fascinating. And most people have never seen that. I’ll try to use what’s fascinating to me to show them that, “Hey, look at what a big difference a little bit of hand gel makes. And you wouldn’t think that but look at it. This is a visual of what it actually does.” I think that showing them the fascinating side of it doesn’t hurt. And I think that’s going to lead more people into it. And also making it easier to get certified. [At one time] nobody wanted to hire you unless you were certified. But you had to practice for two years before you could get certified. It was a Catch-22. I think all of those things are going to lead to more people into infection control in the future, hopefully.

ICT^®: And tracking is one of the things that sets VA infection prevention apart?

Hilliard: Out in the general private sector, they use NHSN. Now we’re all using CDC guidelines. But we view our populations a little bit differently. We all calculate rates based on their days of care and the number of infections that each unit has. But we classify our patients a little bit differently. And that’s just because VA is a little bit different than everyone else. We have specific programs like the National Multidrug-Resistant Organism Office. That is nothing but a VA-based program that puts a person in that position to handle those bugs that are really hard to kill, or that have a high mortality rate, like MRSA in hospital settings. I think the private sector has not set aside a person just to do that. I think that that is two of the biggest differences that I see.

ICT^®: When you talk shop talk with IPs in the private sector do they seem interested in how you battle infection at the VA?

Hilliard: Oh yes. I think so. All the infection preventionists, whether you’re a private or public, are all facing a lot of the same issues. We don’t handle them the same way. But we’re all facing the same issues. With all these cases of COVID-19, all of our reporting requirements have gone up, because everybody at the hospital is reporting just as every COVID-19 case they have, just like I am. And so that is additional job duties that we’ve never had to do before. That’s extra work. And we thought that it would go away after 2020. And it’s two years later, and I’m still putting in 10 to 20 cases a day. So that’s so much more than what we’ve ever had to do for any other virus. For any other infectious process.

ICT^®: The Association for Professionals in Infection Control and Epidemiology [APIC] is lobbying for states to mandate that anybody with the title infection preventionist in a health care setting have certification. Have CIC after their name. Is that already in place at the VA?

Hilliard: It’s encouraged, but it’s not mandatory. It is something they look at heavily when they’re doing hiring. If there’s a certified person, a person who is certified in infection control, interviewing for that position, they’ll more than likely get the job over a person who’s not. I was not certified the first couple years I was here. I let my certification lapse in the private sector when I went to work in an ICU because I didn’t think I needed any more. And so actually, I was not certified when they hired me, but there was no one else certified that applied. And the fact that I had been certified in the past let them know that I had the ability to pass the exam. I think that’s what helped me get in the door here. But there were no certified IPs, not one that applied for this position here when it was posted.

ICT^®: APIC also wants to see a full-time IP in nursing homes. Is that an issue within the VA health system?

Hilliard: Not really. We’re a master of none but a Jack-of-all-trades because we do long-term care and acute care. We do everything. We do ambulatory care. I do all of the outpatient clinics, just like I do the nursing home care facilities. And we have four of those that are operational now. Four separate buildings. One is a memory care unit. One is a hospice unit. One’s a palliative care unit. One’s a rehab unit. And they’re all very, very different. Now there’s not a separate infection control person for that. That is just all me. That’s not something that we see a lot of: more than one infection preventionist unless it is a really, really large facility.

This interview has been edited for clarity and length.