Q&A: IPs at Children’s Hospital Were Ready When COVID Struck

Increasing the staff and influence of the infection prevention and control department at the Children’s Hospital of Philadelphia (CHOP) led to a substantial decrease in the amount of healthcare-acquired infections (HAIs). That’s not all, says Sarah Smathers, MPH, CIC, FAPIC, CHOP’s system director for infection prevention and control. She tells Infection Control Today® that increasing the number of infection preventionists (IPs), allowing better access to the field for those who want to become IPs, and providing a career path all helped to control the spread of coronavirus disease 2019 (COVID-19) when it arrived on the scene. Smathers doesn’t need much of a nudge to extoll the rewards of being an IP. “I love the impact that you have that every day you go into work, you help somebody,” she tells ICT®. “You help a healthcare worker protect themselves. You help them provide better care for their patients. And you’re always learning. You never know everything there is to know in this field. And just when you think you do, there’s a new pathogen to learn about.”

Infection Control Today®: Your recent study in the American Journal of Infection Control (AJIC) concluded that increasing staffing levels in infection control and prevention departments and providing training opportunities and career paths for healthcare workers who want to become IPs helped to drastically reduce the number of healthcare-acquired infections at the Children’s Hospital of Philadelphia. Is that a fair summation?

Sarah Smathers, MPH, CIC, FAPIC: Yes, absolutely correct. We, we actually submitted the paper in late 2019 to AJIC. It was really very much pre-COVID. We didn’t know anything about COVID at the time, and was reflecting upon our experience that really started in 2014. Responding to Ebola at the time. And I have to tell you, I am so grateful that we did this work. That crisis really highlighted the need to grow our department, as well as a growing healthcare system. Because when COVID did hit, we were in a much better position where we could actually utilize these resources in a very creative way to help sustain our response these many months.

ICT®: What I also found interesting is that you created a career path for people who want to become infection preventionists and advance in that field.

Sarah Smathers, MPH, CIC, FAPIC

Smathers: Yes, something that we noticed is that people didn’t really know what we did. And so, a lot of people said, “Oh, your infection preventionists. That’s hand hygiene, right?” And really didn’t understand the scope of our practice. And so, we started a position where we would take a new nurse every year who was interested in learning more, and we had a fellowship program. And so it’s a 12-month fellowship program in our department with a current CHOP nurse who spends part of their time on their home unit, and then part of their time in our department working on developing content expertise, but also working on a project that would benefit the organization or their department specifically. And when COVID happened, we were actually able to pull some of those fellowship grads back into our department to help with the response.

ICT®: What I got from your study is CHOP increased the staff in part in response to Ebola, but also because of healthcare-acquired infections right?

Smathers: Yes. We really wanted to say how do we become more preventive. We’re very reactionary, especially when you’re not staffed appropriately. All you can do is really respond to whatever the current crisis is of the day. And you don’t actually get to do that prevention work. And so we really wanted to focus on giving the infection preventionists the time back in their days and our schedules, to work on prevention projects, to round down the units, to give just-in-time feedback, to provide education in the moment, which we really think helps with preventing infections.

ICT®: Could you give us an idea of how much this improved infection prevention?

Smathers: Yes, so what we did is we looked at some of our key indicators that we track. And so, we track central line associated bloodstream infections, catheter associated urinary tract infections, ventilator-associated pneumonias, healthcare associated viral infections, and surgical site infections. And we saw significant decreases in all of those infections over the time period. We were also doing a lot of other work. So, it’s not to say this is the end-all and be-all, but certainly we were able to participate in a way that we weren’t able to in years past.

ICT®: Twenty-three percent comes to mind. Is that how much HAIs decreased?

Smathers: It was a 33% decrease.

ICT®: When you started, did you expect that kind of success?

Smathers: I think that when we started the program, we really knew that we needed to get infection preventionists out from behind their desk. And it was really a lot of reasons that we thought that they could be helpful in the environment: rounding, doing the education. But really the results when we looked at them, when we were able to look back and say, “Wow, this actually had a really specific impact.” And we could think about the reasons why that supported it.

ICT®: I know your system of tearing infection preventionists dovetails with APIC’s tearing system. How did you manage that?

Smathers: APIC [Association for Professionals in Infection Control and Epidemiology] did publish a roadmap for becoming novice to proficient to an expert infection preventionist. And when they first came up with that concept, I believe was in 2012, I was really intrigued by it. Because our department at the time had one role. So, if you were an IP with 30 years of experience, or an IP just coming out of graduate school with zero experience, you were in the same role. And to me, it felt like if we really wanted to promote this as a career opportunity, you needed to tell people that they were going to be able to advance within their career and have very clear guidance for how to do that. And also get people who were more senior in their career an opportunity to mentor those people and be acknowledged for their senior years in the field.

ICT®: If memory serves, it was infection preventionist 1, infection preventionist 2, and senior infection preventionist, right?

Smathers: Yes, that is correct.

ICT®: Would the senior infection preventionist be the manager of the other two?

Smathers: They’re actually not. We do have infection prevention managers in our department. But what we wanted to provide is there are a lot of people who want to advance through their career of infection prevention and control and don’t want to manage people. They want to be experts in their field, they want to be content experts, they want to work on large scale projects that span the entire hospital or the hospital system. We wanted to give them an opportunity to be able to grow and not have the only opportunity to be managing the department. So, we do have managers, but we also have people who are leaders without [officially] leading people.

ICT®: You used the phrase earlier “get them out from behind the desk” for infection preventionists. So, is the implication that infection preventionists were basically numbers crunchers who didn’t interact with the nursing staff or doctors maybe as much as they could have for better outcomes?

Smathers: Yes, I think that there’s been a change over time in the field. And certainly, when we started, this was still new. It really started about in the 1950s. And it was really a lot of field work for the hospital. And there was a lot of those interactions and partnerships. And then over time,

you started to have mandatory laws, whether that was through CMS. You also have accreditation agencies like the Joint Commission. You have your state mandated laws. And you’re required to submit all this different information to all these different places, and track infections. And in the state of Pennsylvania, where we’re located, we have to track every infection that the CDC has a definition for to the CDC’s National Healthcare Safety Network. And so that’s a significant burden. And in doing so, you are trapped. You’re looking at your computer screen. You now have electronic medical records. When I first started, I would still get to the floor, because the records were on the floor next to the patient’s bed. But over time, we’ve moved to electronic medical records. You’re looking at a screen. You’re completing data. You’re recording data, and that takes a lot of time. And then you’re not able to spend that time up on your units and the departments talking with people.

ICT®: You mentioned when you got started. What is your background? And why did you decide to become an infection preventionist?

Smathers: I have my master's in public health and hospital and molecular epidemiology and it had an infectious disease focus. When I was younger, I read The Hot Zone, which was about an outbreak with the Ebola virus. And I became very, very interested in infectious diseases and outbreaks. And I started doing research at CHOP in infectious diseases. And then doing that research, I was doing research both in the infection prevention and control department and also in the infectious diseases department and realized that I just really loved the field. And I love the impact that you have that every day you go into work, you help somebody. You help a healthcare worker protect themselves. You help them provide better care for their patients. And you’re always learning. You never know everything there is to know in this field. And just when you think you do, there’s a new pathogen to learn about.

ICT®: We won’t mention any names, right? I am interested in the Children’s Hospital of Philadelphia. Healthcare professionals have complained justifiably about the shifting guidelines when it comes to COVID-19. In the beginning, we were told that we really don’t need to worry about children getting it. You said that when COVID struck, your department was ready to roll. Did you roll right away? Or were you stopped by the news that this really doesn’t affect children? Or were you worried about your fellow professionals?

Smathers: We do we worry about our employees, as well as our patients and our visitors. Anybody who’s coming into any of our CHOP patient care buildings we need to take care of. And so, we had actually started working. Our bio-response team has been active since the days of Ebola. And we have been training and preparing. We meet quarterly. And when we started seeing what was happening out of China, we started meeting in early January, and upped those meetings to really every week. And as it became more and more apparent, then they became daily. We were not pausing because there was information that it didn’t impact children. But you know, at that time, we knew things could change. We knew that that was the results out of China. But we were still really worried about what it meant for patients, our patients who are immunocompromised, who have had organ transplants. And so really, we didn’t know what it meant for our chronic kids—our kids with chronic conditions. We were being cautious and we really wanted to make sure that our employees were prepared. Because our patients don’t come in alone. They come in with family members, and those adult family members could be sick as well.

ICT®: Did more and more departments participate in those daily meetings as time went on and the pandemic got worse?

Smathers: Our bio-response team is a multidisciplinary team that includes all aspects of the hospital and very early on we really created about nine different workstreams where we knew we were going to need to focus on things like logistics. Do we have the right supplies? Do we need to create the right environment for our patients? So, where are we going to house those patients? How are we were going to train people for PPE. How are we were going to deal with the surge? We created different streams of work to respond to the different areas that we anticipated needing help. And then as new things popped up, we formed new working groups. And you know, within the first couple weeks of the pandemic, we set up a contact tracing center. That was a great collaboration between our occupational health department, infection prevention, and our poison control center. We had a call center for employees and patients.

ICT®: How many hours were you working during the spike? Was there a spike at CHOP at all?

Smathers: I think that we were expecting—when we were watching what was happening in New York City—we were very, very concerned for the Philadelphia area. I think that it was better than I could have hoped for. But it was certainly pretty stressful in those beginning few weeks and months, as we didn’t know which direction we were going to go and we were watching as New York and New Jersey really skyrocket.

ICT®: I always got the feeling that infection preventionists, before COVID-19, felt a little out of the loop. Will COVID change how infection preventionists and infection prevention departments fit into the hospital hierarchy?

Smathers: I think it will. I have to say, I am very grateful to work at the Children’s Hospital of Philadelphia, where I don’t feel like we’re often left out of the loop of operations. I think people really do reach out to us. I think some of that stems from the foundational work we have done since Ebola to integrate ourselves more into operations. I’m hearing from a lot of peers, that that is exactly what they’re hearing from their administration: “We don’t have you resourced enough. How do we staff you differently?” And I’ll tell you, I think that hospital administrators are concerned about how they’re going to recruit in a field that is expecting a lot of retirees: 40% of infection preventionists are expected to retire in the next five to 10 years. And so, we need to really be thinking about how we recruit the next generation, how we train them and how we prepare them. Because it’s not an easy job to begin with. And it’s just getting very much tougher since COVID.

ICT®: Where from here as far as recruiting infection preventionists at CHOP?

Smathers: I can tell you what I did is several years ago, I reached out to Drexel University and I asked if they would be interested in developing a certificate program and their master’s department at their Dornsife School of Public Health. And I worked with their team there to develop a curriculum. I teach a course on infection prevention and the healthcare environment that people can either minor in or professionals can get a certificate online. And we have gotten some great feedback that people who have graduated from that program have gone on and been able to get positions in infection prevention and control, where typically somebody with my type of background it was very hard to get into the field.

ICT®: Anything you want to say to your fellow infection preventionists around the country who might want to follow in your footsteps and steer more hospital resources and people into the department?

Smathers: I can tell you I was asked recently, what is the one thing that I really felt like made a difference in decreasing HAIs? And I will tell you that I really think it was the role diversity. So, having different types of roles in the department that do different tasks. And so, when COVID hit, we had infection prevention associates who were doing some surveillance for us. Doing our reporting, our data entry. When COVID hit, they went 100% home and did all 100% of our surveillance with one infection preventionist and then that let the rest of us who were in the hospital to focus 100% of our time on COVID. We were able to keep the wheels on the bus that way through having these different roles that could kind of flex up when we needed them to and allow our infection preventionists to do their job in the hospital.

This interview has been edited for clarity and length.