Q&A: CDC Wants to Help Infection Preventionists

Think of it this way, says Michael Bell, MD, the deputy director of the division of healthcare quality at the US Centers for Disease Control and Prevention (CDC). A lot of what infection preventionists (IPs) do involves educating their fellow healthcare workers about proper methods of infection control and prevention, some of which have become much repeated by healthcare experts since the beginning of the coronavirus disease 2019 (COVID-19). It’s in part because of what the healthcare system has gone through with the pandemic that the CDC just launched Project Firstline, its $180 million effort to train everybody who works in a hospital about infection prevention. “I think the more we can get the entire healthcare community on the same page related to the basics of infection control, the better off we’ll be,” Bell tells Infection Control Today®. And he does mean everybody, from hospital administrators and top surgeons to environmental service teams and security guards. Bell says that “many, many professions that have as much need for this knowledge don’t have the luxury of time allotted for training. If you finished a 10-hour shift in a nursing home, it’s 11 o'clock at night, and you’re expected to sit down for 45 minutes and watch a webinar, that’s probably not going to happen very consistently.” Project Firstline will make the IP’s job easier, contends Bell. “If there are other people who recognize things like hand hygiene opportunities, or other lapses in infection control, and can point that out, then it won’t be just the infection control professionals, the experts, who have to do that particular thing.”

Infection Control Today®: Tell me a little bit about Project Firstline? I understand that it grew out of discussions that the CDC had with some frontline healthcare workers?

Michael Bell, MD: Project Firstline is a very different take on training than we’ve done over the past 30 years. Training is nothing new when it comes to infection control. But most of the training to date has really focused on supporting our main points of contact; our lead infection control professionals, hospital epidemiologists, and so on with an understanding that they would then reach out to the rest of their colleagues and support their training needs. This time, we’re actually reaching to each and every frontline health care worker. This ranges from obviously nurses, nursing assistants, dialysis techs, environmental services staff, radiology techs, physical therapists, emergency services staff, you name it. All of these people have very important interactions with our patients and with each other. And it’s become very clear that simply sharing the rules, and the top X number of things they should be doing really isn’t enough. As you mentioned, we’ve done a lot outreach. We have excellent partners across the spectrum of healthcare, and frankly, across the country. To help us reach the variety of staff, the variety of people and cultures that we need to embrace to make this work well and have done listening sessions with those partners over the past several months. That’s helped us identify not only the content type needs that people are interested in, but also the types of delivery and the tailoring that we can do to make it more useful for everyone.

ICT®: Where do infection preventionists fit in this?

Bell: The way we envision this is that it will make their jobs easier. If everyone understands the basics, and the rationale behind infection control, then when the infection control professional comes and says “We need to do this, this and this,” it’ll be much more intuitive and much less of a lift, frankly, to get everybody on board. The reality is that infection control professionals are

Michael Bell, MD Deputy Director, Division of Healthcare Quality US Centers for Disease Control and Prevention

very, very stretched in most facilities where they exist. They’re having to collect data. They’re launching bundles, and ensuring that people have the tools they need to do that. There’s a lot to be done already. And it’s very difficult to think about that small number of individuals actually reaching the hundreds, if not thousands, of people in their facilities to do the kind of training that we think is needed. In addition, we’re not in the situation that we were in 30 years ago or more, when most healthcare took place in hospitals. Hospitals still have the luxury of infection control staffing, robust environmental services, central supply for disinfection, sterilization, all of those things. But increasingly, healthcare has moved to long-term care facilities. It’s moved to ambulatory settings. And a lot of those places don’t have that kind of expertise or resource. And so, ensuring that we can reach everyone wherever they’re providing care is also part of the plan with Project Firstline.

ICT®: I’ve reached out to some of our Editorial Advisory Board members and they’re all thrilled that the CDC is doing this.

Bell: The content is going to be available by the end of this coming month. And modules will be added in terms of topics over the course of several months. The initial modules are addressing the fact that many of us are struggling with COVID-19 and need to make sure that we and our colleagues remain safe as we respond to the pandemic. So, the initial modules are framed around COVID. They’re also framed around the needs of long-term care facilities. As you know, we’ve had some very tragic outbreaks in nursing homes and trying to do all we can to prevent that is also part of the mission. But over the course of time, we will be expanding the content to cover the waterfront, as you already alluded to. It’s a very broad range of infectious disease threats that healthcare professionals have to deal with every day. And making sure that they’re equipped to understand not only the what, but the why behind the what. And also, people recognize risk when it’s near them. And by that, I mean, I really hope that we can move toward every healthcare professional, regardless of their role, being able to walk into a room and quickly notice if something is wrong. For example, if there’s a coughing patient, in the waiting room of an acute care facility, an emergency department, or even a clinic, having everyone recognized promptly that that person needs to be moved to a private room, while they’re waiting to be seen, as opposed to potentially exposing a bunch of other people in the waiting room. That kind of basic response is something that we’d like to see happen everywhere.

ICT®: Basic response. It’s always shocked me—and you know better than I—how hand hygiene has been an issue for decades. Healthcare professionals just don’t practice it the way they should. Hopefully, after COVID, they will. But it’s the sort of thing that you wonder if they’ll let their guard down once the immediate danger is passed.

Bell: I think the reality is we’re all human. And when we frame training as remembering these five things, and it stops there, once the circumstances change—whether it’s because we’re no longer feeling directly at risk, or because our environment is different and the framework that we were taught doesn’t apply as clearly—I think it’s very easy for practices to drift. On the other hand, when people understand the why behind what we’re asking, I think they’re more able to carry it with them and maintain a practice. An example, you mentioned hand hygiene. I think there’s probably not a single healthcare worker in the country that thinks hand hygiene is bad. But I do think that there are people who may not think about all of the times they need to do that. And recognize the impact that that can have. An example is cleaning your hands before putting on non-sterile gloves. A lot of people will react to that and say, “Well, I’m putting on gloves. So why do I need to clean my hands? I’ll clean them as soon as I’m done and take my gloves off.” But the rationale is if you’ve got something on your hands, and you reach into a glove box, a box of clean gloves, and contaminate them, not only are you then contaminating the gloves you’re putting on, but you’re contaminating other gloves that other healthcare workers are going to have to reach in to use. Putting both them at risk, and their patients. So that kind of rationale is why I want people to be thinking about. Once you think of it that way, it becomes second nature that you would want to have clean hands going into a box of gloves.

ICT®: Is Project Firstline a direct result of the COVID-19 pandemic?

Bell: Project Firstline is a combination. We have been training people at CDC and around the country and around the world, in infection control practices for a very long time. Over the past 35 or so years of effort, we’ve seen the target change. I think that’s when this began. The target was infection control professionals. And that was probably sufficient at the time. But as time has passed, the challenge that infection control professionals face has grown tremendously. We’re asking these individuals to not only be experts, but also to take responsibility for such a wide range of activities in a vast, vast setting, and finding ways to help them accomplish what they’re doing across the whole population of healthcare personnel is the rationale behind Project Firstline.The pandemic, just like every major outbreak that we’ve had, always underscores the areas where we need to strengthen infection control. It also underscores the fact that people forget they need to be reminded. And so, having a way to do that effectively is part of the mission of Project Firstline. I mentioned getting a lot of input from partners across the country. Some of that is about understanding the needs of people who may not work in professional capacities that provide time for training. We often think about the nurse or physician paradigm of being given time for on-the-job training, or continuing education type learning. But many, many professions that have as much need for this knowledge don’t have the luxury of time allotted for training. If you finished a 10-hour shift in a nursing home, it’s 11 o'clock at night, and you’re expected to sit down for 45 minutes and watch a webinar, that’s probably not going to happen very consistently. On the other hand, if we can package things in small bites, eight or nine minutes, ideally on something that can be used portably on a smartphone or tablet, that opens up the possibility for people to receive the training while they’re commuting, maybe on a bus or in a carpool, or even at home, when they have a few minutes to themselves. I think that kind of flexibility is very much a new approach that’s been led by all of social media around the world. It’s a different generation of learners and accommodating them and their needs is part of the mission.

ICT®: Would a correct metaphor be something like even though we’re not all nurses or emergency medical technicians we should perhaps know what to do when somebody’s choking in a restaurant? Is that a fair metaphor of what you’re trying to do with healthcare workers in general?

Bell: I don’t think that’s a bad example at all. I think that’s a good example. We actually have anecdotes about injection safety errors being identified by the receptionist. There was a case about 12 years ago in New York, where a clinician readied syringes to administer vaccines to several people. The receptionist noticed and said that, “Based on what I read in the papers last week, you’re not supposed to do it that way. We probably need to call the health department.” And she was right. That kind of awareness. I also likened it to the reaction that we would face if either of us walked into a hospital anywhere in this country and lit a cigarette. Everyone, regardless of their role, including patients, would jump up and say, “No, no, no, no, no! You can’t do that in a hospital.” Back in the day, there were cigarette burns everywhere, and cigarette machines in the waiting rooms, right? But we’ve changed culture. We’ve now taught people that that’s not OK. And everyone is on the same page. I think the more we can get the entire healthcare community on the same page related to the basics of infection control, the better off we’ll be.

ICT®: Infection preventionists say that sometimes they feel like the hall monitor or the hand hygiene police. Will Project Firstline help them to feel more accepted by the rest of the hospital? Not that they don’t feel accepted now, but some have used those similes.

Bell: I think with any luck, they’ll have help doing their jobs. If there are other people who recognize things like hand hygiene opportunities, or other lapses in infection control, and can point that out, then it won’t be just the infection control professionals, the experts, who have to do that particular thing.At the same time, I don’t want to diminish the importance of having an authoritative infection control professional who can walk around and make corrections gently and be the source of advice and instruction in response to a recognized problem. But I think helping recognize the problem is something Project Firstline can do.

ICT®: Is there something about Project Firstline or infection prevention in general that I neglected to ask you about, that you think is pertinent?

Bell: Well, I think that one other aspect of Project Firstline that isn’t immediately obvious is related to those many partners that we have connected with. And the approach to interactive learning that we are we are building here. There are easy, portable, small nuggets of information that we want to distribute. But as important will be an ongoing series of interactive opportunities. I hesitate to call them town halls because that sounds kind of hokey. But an opportunity for people to raise challenges that they’re having within their own facilities. Especially facilities that might not be attached to a tertiary facility, might be far from an urban center where they can easily reach consultation. If we can bring more information to them, hear their specific concerns, and then let others listen into the discussion. And we’ll learn from that as well. I think that kind of personalized learning is something that we can bring to bear that may make a big plus, certainly right now because of the pandemic. We’re doing a lot of remote interaction like you and I are, and that’s a good thing as well. I think we can leverage what we’re doing because of the pandemic, to then in the future, prevent the spread of infections.

This interview has been edited for clarity and length.