Q&A: Even COVID-19 Might Not Be Enough to Improve Infection Control’s Standing

Michael L. Millenson is an internationally known healthcare expert whose focus is the quality and safety of medical care. An adjunct associate professor of medicine at Northwestern University’s Feinberg School of Medicine, Millenson started his career as a healthcare reporter for the Chicago Tribune, where he was nominated for a Pulitzer Prize three times. He recently sat down with Infection Control Today^®to talk about the sorry state of infection control before COVID-19, and whether the pandemic will force hospital systems and government agencies to take infection control more seriously. 

Infection Control Today^®: Infection preventionists are rock stars now because of COVID-19. But what happens after the crisis passes?

Michael L. Millenson: My wife’s sister is an infectious disease doctor. And even the infectious disease physicians, much less the nurses and others, complain about being pretty low on the totem pole. It’s really kind of interesting in some ways, perhaps because infection control seems, quote unquote, commonsense. Don’t we know how to do that already? We don’t acknowledge what a poor job we do often of actually implementing what we know how to do. And I think that’s really, to me anyway, one of the most frustrating things. We have interventions that we know how to do. We know they’re important. You see all the time the World Health Organization and the CDC [US Centers for Disease Control and Prevention] talk about how important hand hygiene is, and we’re not implementing it. And perhaps this crisis will highlight pretty starkly how important implementation of infection control really is.

ICT^®: You mentioned hand hygiene. Why is that such a perennial problem? 

Millenson: Ignaz Semmelweis discovered the fact that hand hygiene was important to infections around 1847. And he ended up in an insane asylum after trying to push this. So that’s the progress we’ve made. When you insist on infection control, they no longer put you in an insane asylum. So, we’ve solved that problem. There we go. Now to get to actually wash your hands, that’s a little tougher. The most important issue is that we don’t measure it. So, people think they’re doing it, and they’re not actually doing it. And then there are no standards. The Joint Commission and the Medicare program do not require you to show that people wash their hands 80% of the time, 90% of the time, whatever number you might choose. They merely require you to have a program to improve handwashing. If you go from 15% to 16%, to 17%, but of course, you could even stall at 20%, as long as you have that program in place. The people who are not washing their hands don’t see that they’re not doing it. They don’t see the consequences. And we don’t hold anybody to standards to force them to see it. It’s really kind of frustrating. The other thing, which is frankly, embarrassing from an ethical point of view, is when you look at the numbers for transmission of infections from patients to providers, such as HIV, which is a very serious infection, although it’s now a little bit more controllable, you see that providers take hand hygiene prevention measures very seriously. And the CDC numbers show that providers getting infections from patients with HIV has dropped almost to nothing. On the other hand, providers giving infections to patients continues to be a problem. And that’s kind of ethically embarrassing. When the providers are harmed, we make sure it doesn’t happen. But when the patients are harmed, because we don't see it in the same way, we don’t take the same precautions. That’s very troubling.

ICT^®: Do you see the monitoring role of infection preventionists sometimes causing resentment among other healthcare workers? 

Millenson: And I think that’s a shame that you know, you become the hall monitor, the teacher’s pet, the people hitting your knuckles with a ruler. And that’s really unfortunate. There are electronic monitoring systems now. There are sensors you can wear that takes away a lot of that. And I think those are going to be where we’re going or we should go. We should be monitoring in a way that gives us data. You have several companies who do this. You have some hospitals who have definitely started doing this. We should use data, and we should use it because people who are in healthcare do care, in fact, about patients. They care a lot. We’re seeing that now where people are willing to put their own well-being their family’s well-being at risk to help patients. Show them the data, give them the data, show them what’s happening, what’s not happening, and show them the consequences. It is really inconceivable in some ways from a commonsense point of view that the CDC doesn’t even know what the handwashing rate is. They haven’t monitored it for at least 50 years. And that just sort of under 50% is not a crisis. I assure you, if there was a handwashing rate of under 50% that was causing nurses and physicians to get sick or die and we could say that’s why, the handwashing rate would go up. 

ICT^®: Do you see COVID-19 changing the way we go about infection prevention forever? 

Millenson: With COVID-19-even in hospitals which are not seriously affected by it-people can see what’s happening to folks. They can see the consequences in front of them for patients, and they can see the consequences in front of them for providers. People like doctors, nurses, EMTs-just regular people in the hospital-are getting infections and they’re being seriously ill and they’re dying. And I think that makes infection top of the mind, as we come out of this. Having said that, it’s really important to build on that momentum. It’s really important for infection control professionals to build on that feeling of all of us are in this together, all of us are affected. All of us want to see this change and use that sense of social solidarity to get out of the obscurity that unfortunately too often they’re in and become top-of-mind priority for administrators, for chief medical officers for folks like that. That’s my hope that “there but for the grace of God go I” is a feeling that persists long enough for us to do some of the changes that are long overdue.

ICT^®: Will infection preventionists be more prominently given a seat at the table of hospital administration after COVID-19?

Millenson: I think the seat at the table thing is difficult. You know, we’re in a crisis now. Infection control is absolutely the top of everybody’s mind. On the other hand, it is not hard to think that when this crisis is over, the chief financial officer and the chief medical officer come in and say, “You know what, we gave up elective surgeries for all these months. We’ve lost a huge amount of money. The most important thing we need to do is get our orthopedists back operating, get workflow going get, you know, all sorts of things. And by the way before this crisis, our infection control was fine anyway. Nobody was worried about it before the crisis. We’ll go back to where we were.” I think it’s going to be important for infection control professionals to show that things weren’t so great beforehand, and to show that the kind of things that we were doing during this crisis are to the economic and clinical and, frankly, the ethical benefit of the hospital. So there’s an opportunity not to lose your seat at the table because if we don’t take this opportunity, we know that things are going to go back to not only what they were, but we got to get some revenue here to generate and, you know, turn on those hip and knee replacements and let’s get in a little cosmetic surgery and get this place moving again.

ICT^®: Do you see the CDC stepping up infection prevention and control efforts? 

Millenson: No, I don’t. I mean, it’s possible that the CDC will get religion. You know, they have not measured the hand hygiene rates since 1982. They put out patient safety kinds of things and say, ask your clinician or staff person to make sure they wash their hands as opposed to the CDC talking directly to providers. I think that after this, they’re going to be dealing with a lot of political consequences of poor performance, frankly, in COVID-19 and trying to do anything on hand hygiene is not going to be anywhere on their agenda. I’d be happy to be surprised. But the politics of it, aren’t there. This is going to happen at the grassroots. It is possible Medicare programs would put in handwashing standards. You have to reach 90%. If the government does something after this, then I think you know, from CMS [Centers for Medicare and Medicaid Services], I think that’ll be possible. But CDC, I don’t see doing it. The Joint Commission is dependent on the fees that hospitals pay. They are a paper tiger. In 2016, they put in a standard saying if during a survey a surveyor sees you not washing your hands, you get an automatic demerit. [The Joint Commission] celebrated this as some incredible achievement when it came 16 years after they first required a hand hygiene program. The Joint Commission is a paper tiger. The CDC doesn’t really care all that much except, you know, in its official pronouncements that officially cares. If we're going to have any sort of kick in the rear, it’s going to have to come from public pressure or from the Medicare program.

ICT^®: Could a lot of the frustration with not hitting infection prevention marks spring from the fact that a lot of what’s involved isn’t easily measured?

Millenson: That’s a fair point. What can we hold people accountable? What can you measure? And clearly, as we see with C. diff: Does it come from inside? I mean, there’s a lot of room for debate over accountability, and you do not want to be punitive. At the same time, if you never set a goal of 100% …  as we’ve seen with CLABSIs [central line-associated bloodstream infections], people thought, “Look, you can only get down to a certain rate and then you can’t go any further.” And then we showed with the Michigan hospital experiment, that in fact, you could get down to close to zero for sustainable periods of time. Not always. Not always sustainable. And frankly, that was around 10 years ago now. And it still hasn't been implemented. Right? We still don’t say “Look, if we show we can prevent infection, why don’t we do it?” Remember, these are not expensive interventions? These are not interventions that require a lot of money. What they do require is a lot of management time and commitment. And so the question I ask when I give talks is, explain to me your justification for not first do no harm? Explain to me why building a new atrium is more important than putting into place processes that you know will prevent often life-threatening infections like CLABSIs. We wouldn’t accept: You know what? We’ve decided to give chemotherapy to breast cancer patients. We know it’s been in the literature for 10 years, that this therapy works, so we’re going to start doing that. I mean, that would be shameful. But when it comes to infection control, apparently there’s no shame in taking years to implement things that other people have done many years ago. And that just floors me that we look at infection control as something that we can take our time with and we should give everybody a pat on the head that they did it and look they’ve gone from, you know, 40% handwashing to 60% handwashing to 50%. There’s a saying in journalism, tell it to Mom. Put things in simple language. If you went to your mother and you said, “You know what? Doctors and nurses in our hospitals are supposed to wash their hands all the time, but we’ve been about 40% for, you know, 10 to 15 years, but within a year, we went to 60%. And we gave everybody a party.” She’d go, “Wait, 60% is OK?” It just defies commonsense and ethics for us to treat infection control as something where slow improvement is okay. And I’m sorry, I’m a bit of a militant on this.

ICT^®: You’re internationally known healthcare expert. Is anybody doing this right? 

Millenson: I think the Scandinavian countries take this more seriously in terms of system improvement than we do. The reason other countries have the same problems we do with medical error and patient safety is the context in which doctors and nurses are trained in Western medicine. The doctors are kind of in command, and nobody calls them to account and they’re not measured, or they’re not managed, and they’re smart people trying to do their best. And therefore, if stuff happens, well, you know, the patients were sick. And that has a germ of truth. But what it doesn’t take into account is that systemic improvement, even for smart people, even for people who are trying hard, results in safer care and better care. So other countries have the same issue we do because doctors are trained in the same way, nurses are trained in the same sort of construct. But I think some of the single payer systems have done a better job, in part because the costs are obvious, right? The costs go to the government, they go to the taxpayer. In our crazy payment system, there are unfortunately hospitals who believe that infections are profitable. This is a not very well-kept secret. This is ethically insupportable, it is outrageous, it is wrong, and what anybody in medicine should be doing-and I understand why people at the bottom of the food chain think they cannot-is not trying to persuade the hospital administrator that stopping infections will make you money. It’s saying we have an ethical obligation to stop infections. It is ridiculous to spend 10 years however long we’ve been doing it trying to persuade people that it’s worthwhile putting your money here. I understand there are different priorities. I understand that money is not always available. But again, you know, I’ve been in the trenches. The hospitals that are not doing this are not all safety-net hospitals that can’t afford it. They’re not people who are living hand to mouth. They’re people who are building beautiful new buildings with gorgeous skylights and going around the country to recruit surgeons, and they’re not giving the money and the management attention they need to give to infection control. How can you allow an infection to happen that you could prevent? How can you allow people who trust you and who care for you to be harmed? And we’re seeing this with COVID-19. And we’re calling clinicians heroes. And they are. But even heroes need to come back to earth and say, “You know what, that was a crisis. In everyday care, we need to have that same attitude, that same compassion, that same caring and trusted stewardship attitude toward our patients.”

ICT^®: Do you have any final words for my readers who are on the frontlines these days?

Millenson: I think they should know that people who really understand what they do appreciate them. I think they should think about how they could organize, if not in individual hospitals, then in professional groups, to speak up more. I would say to infection control professionals that when things go back to normal, they won’t automatically change. How can you as infection control professionals throughout all the ranks-physicians and others-how can you not waste this COVID-19 crisis? And I understand we’re in the middle of it. And that’s not something that often people who are working as hard as these folks are can think about. But I would say that as we emerge from the COVID-19 crisis, it’s very important for infection control professionals to think, “How do we take this crisis and use it as a lever to cause the change that we care about so much?”

This interview was edited for clarity and length.