Stimulus Will Boost IP Efforts, but Cultural Change Needed

It’s no surprise that the internationally known health care expert Michael L. Millenson got his start in journalism as a health care reporter at the Chicago Tribune, where he was nominated for a Pulitzer Prize three times. Millenson, currently an adjunct associate professor of medicine at Northwestern University’s Feinberg School of Medicine, can boil complicated ideas down into digestible material—soundbytes, even—that can be appreciated by experts and lay people alike. Since the advent of the coronavirus disease 2019 (COVID-19) pandemic, Millenson has focused some of his attention on the state of infection prevention and control in health care. In one interview with Infection Control Today®, he noted that the health care system in general, and the Centers for Disease Control and Prevention (CDC) in particular, have historically been negligent in this area. He has subsequently softened his view, calling the CDC’s Project Firstline—which strives to teach all health care professionals about the importance of infection prevention—a good first step and saying that the pandemic in general should make everybody more aware of IP issues. Now, Millenson tells ICT® that the recently passed $1.9 trillion stimulus could also prove vital in infection prevention efforts, because it includes an infusion of money to hospitals. “If you take some of the financial pressure off of hospitals and you combine that with, hopefully, a renewed sense of how important infection control is to the centrality of their mission, that opens up a space for administrators to listen about infection control in a way that perhaps that listening wasn’t going on before,” Millenson says. But so much of improving IP depends on cultural change, and that’s never easy to do.

Infection Control Today®: What’s your take these days on Project Firstline?

Michael L. Millenson: All of us, of course, are hoping to return to normal as soon as possible, which might or might not be soon. Project Firstline is fascinating because what it is, is the CDC getting together with a whole range of medical and nursing and health care groups to try to improve infection control among all health care workers in terms of the spread of infectious conditions. But also, it’s going to kind of cascade down to preventing infection transmission to patients as well. What makes it really interesting is that it is incredibly broad, like not just hospitals, but health care workers in whatever setting they might be. And it’s affecting workers as well as, hopefully, patients. It’s got a large coalition of groups behind it. And they’re trying to do some interesting things with technology, which think is really important.

ICT®: What kinds of interesting things with technology are you thinking about?

Millenson: They know that with a relatively small budget, they can’t be having meetings with every health care worker in person…. To give you an idea of their budget, their budget for two years, is $180 million. I want to get a little bit of perspective on how much money that is to cover every hospital in America, every nursing home, every ambulatory care facility It’s roughly the

Michael L. Millenson

revenue of one Costco warehouse for one year; to cover everything [in health care] in two years, right? It’s not a lot of money. So, what are they trying to do? Well, one, they’re trying to have videos, sophisticated videos, that maybe will be powered by AI to be tailored to the individual health care worker and their interests and make it a lot more effective. They’re doing some technology in terms of trying to figure out how to stop infection from spreading. One of the fascinating things is that they’re talking to the Applied Physics Laboratory at Johns Hopkins about airflow in different health care environments. They’re trying to use, obviously, the web and a lot of other outreach. They realize they’re limited, but they’re trying to be innovative in terms of getting their message out.

ICT®: Where does the recently passed huge stimulus bill fit in all this?

Millenson: From the point of view of infection preventionists, the important thing is very simple. The important thing is one, some hospitals are getting more money, particularly rural and some underserved hospitals. That’s a safety net to protect against layoffs, and to ease some of the sense of desperation. And that’s really important. The second thing is, is that we’re giving insurance coverage eventually over the next couple of years, to 2.5 million Americans. And we may also be expanding Medicaid in states that have not expanded Medicaid to millions of more people. Now, why is that important? It’s important because often hospitals have stinted on infection prevention for financial reasons. And the pandemic hasn’t helped. As you know, the optional kinds of care have dropped considerably and surgeries have dropped. All these kinds of things that we took for granted would never be affected by anything: Well, if people are afraid to come to you physically, that’s going to affect your revenues even with telehealth booming in a way that was never thought of before. If you take some of the financial pressure off of hospitals and you combine that with, hopefully, a renewed sense of how important infection control is to the centrality of their mission, that opens up a space for administrators to listen about infection control in a way that perhaps that listening wasn’t going on before. So that’s what makes me cautiously optimistic. Because unfortunately, history tells us that when economic pressure sometimes eases people go back to old habits. Our opportunity is not to go back to old habits.

ICT®: We have on our Infection Control Today® website currently an article, by one of our excellent contributors, Jan Dyer, who basically says it’s still not a question of if, it’s still a question of when, and that the next pandemic might be caused by bacterial superbugs. In your judgment, is this going to be an every 100-year thing? Or is this going to start being an every generational thing?

Millenson: That’s a great question. And, you know, the 1918 pandemic—the great Spanish flu pandemic which killed millions of people across the world—happened at a time before television, before the internet, before much instant communication, and people had a much longer attention span. And we—confronting a pandemic with a very limited attention span—want it to end quickly, because, hey, we don’t have any attention span for long pandemics. This should be over. A year? Are you kidding me? Nothing lasts a year. It’s not that interesting anymore, right? Well, unfortunately, the actual biological virus causing the pandemic is not aware of our attention span. Right now, we’re really balanced on a kind of tension between: We’re going to have this under control, and new variants are continually going to challenge us. Nobody knows what the impact is of these new variants will be. But if you step back and you get away from what we all hope will happen for a moment. It’s hard to believe that with variants spreading all over the world and everybody easing up, that this is not going to be a constant fight for a long number of years to come. Now, will science triumph? And no matter what happens to variants, we’ll control them, we’ll find a way to have booster shots constantly, the entire world will be vaccinated, and everybody will live in peace and harmony. And it won’t matter to us in America that there are underprivileged people not getting vaccines in South America, or whatever. That’s a nice scenario. It’s hard to believe in that quite yet. But it’s a nice scenario to hope for.

ICT®: Do believe that the CDC will start paying more attention to infections in general? I guess Project Firstline is the answer. They have at this point.

Millenson: Yes, I do believe the CDC will pay more attention to infections. But there’s also an asterisk here. Will Congress continue to pay attention to infections? Will the administration’s budget continue to pay attention to infections? Will the media continue to pay attention to infections? To a certain extent, agencies like the CDC are whiplashed by political and public fashion. And goodness knows enough people have died that this isn’t going to fade anytime real soon. But the CDC has to be aware of what Congress and the public and all the rest of these folks want. I think for the next few years, it’s hard to believe that the CDC will not be paying a lot of attention to infections, not just because of what’s been happening out in the real world, but frankly, look at the personal experience of individuals at the CDC, of individuals in Congress and elsewhere. The people who have power have also experienced this pandemic, and I think that’s going to have influence for now. Again, the ability of people to forget things should not be underestimated. Remember, after 911 happened, we’re all going to change the world forever. Forever didn’t last that many years.

ICT®: We still have to be searched at airports.

Millenson: That we do, but some of the unity didn’t last that long. Will we have some infection control of stringencies that stay? I think we will. I hope we will. I think everybody’s heard about hand washing at least. But it’s hard, right? I mean, behavior change is hard. And that’s really…. Some of the tension that’s coming in here. To what extent can we put in technology that causes the infection risk to be lower? And to what extent do we have to have behavior change by individuals, particularly by nurses and by doctors, which is a lot harder? There’s a tension there about what we implement between what’s easy to stay to what’s a little harder to stay. We’ll see how that plays out. What Project Firstline is trying to do is—which is hard, but worthwhile—is cultural change. How do we educate people who really don’t know much about infection control—about what they really need to do to help to change the culture? And if you can do that, that’s really where we need to go. That’s hard. But we have a head start with the pandemic.

ICT®: It always surprised me how hand hygiene compliance rates have been dismal over the decades for health care workers.

Millenson: Absolutely. And by the way, health care workers refusing to take the vaccine surprises me. They’ve been taking flu vaccines and other things forever. The way that disinformation and misinformation has affected even people who are working in nursing homes and hospitals has surprised me. I think hand hygiene rates will be higher for a while but will not stay higher unless there’s cultural reinforcement. All the literature tells you that people think they’re washing their hands and they think they’re not causing problems. How are we going to have that cultural reinforcement? Maybe Project Firstline will help. But that’s really where I think infection preventionists have the opportunity to help change the culture at their own institution. You get senior management more aware of this, and have this more of a priority, because it really has to come from the grassroots. While we have open minds, while we have some momentum, frankly, while we have some fear, right? Fear is a great motivator for change. I could get sick. That’s a motivator more than some other people might get sick.

ICT®:I f you ran the health care system in United States where would you put infection control on your list of priorities? And what would you do about it?

Millenson: Well, look, if it’s going to be a priority, you have to link it to COVID-19. But that’s where the priority is. And I might hold a series of very public [meetings] about changing culture, where I’d have infection preventionists, and senior executives from hospitals, and physicians and others, and have sort of a public kind of…. You know, we in the government care about this. How are you going to change your culture? Because the key is to build a high reliability organization. And building high reliability organizations has been a priority in certain industries—like nuclear power plants, and airlines—and not as high a priority in other industries like health care. That’s why I’ve talked about it. And so, if you want this to be self-sustaining, you have to change the culture, really change the ambitions. And it’s not that people in health care don’t care about it. It’s that it has trouble bubbling to the top of the list of things I have to do. And if you’ve got some of that public pressure, some of the public, frankly, publicity simply about what it means, you can start to change the culture. And that’s what I would do, because you can’t put in any regulation that does it. For better or for worse, this is not “wave a magic wand” and the Federal Register makes the problem disappear. It’s not bad guys, so you don’t have any villains. If you don’t have villains, and if you don’t have an easy technological fix, what you have is a behavioral change problem. Those are difficult. But the COVID-19 pandemic has opened minds, opened hearts, maybe even opened a few wallets. Let’s see what we can do to take advantage of that.

This interview has been edited for clarity and length.