The Shifting Responsibilities of Infection Preventionists

Infection preventionists

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The role and responsibilities of infection preventionists (IPs) have changed over the past 75 years.¹ Initially, this role was established following recognition of the need for surveillance of nosocomial infections in the 1950s.¹ Early IPs were nurses experienced in bacteriology and infection surveillance and understood the importance of personal hygiene and environmental cleanliness in health care.² Typical tasks for the early IP included creating infection lists, reviewing infections and mortality rates, being aware of any staphylococcal epidemics or penicillin failures, and knowing isolation protocols and education on infection control.²

With the implementation of the CDC’s National Healthcare Safety Network (NHSN) and the founding in 1972 of the IPs’ professional organization, the Association for Professionals in Infection Control and Epidemiology (APIC), the “era of expansion” for infection prevention began.³ With the advances in medicine, patients were at higher risk of infection with the use of devices that resulted in breaking down a body’s defense with entry through the skin or the use of an artificial airway.³ IPs were called upon to perform research to identify ways to prevent infections for the most vulnerable patient populations, coupled with increasing surveillance responsibilities in all units instead of only intensive care units.³ IPs also began learning about how the environment plays a role in transmitting pathogens in health care and the importance of cleaning and disinfection.3 Additionally, data from the CDC’s Study on the Efficacy of Nosocomial Infection Control Project indicated a strong association between prevention efforts and a reduction of nosocomial infections, along with decreases in treatment and length of hospital stay.⁴ It also suggested that one-third of all nosocomial infections could be prevented if the facility employed a minimum of 1 full-time IP for 250 beds.⁴

The 1980s, the “era of reaction and response,” brought new levels of responsibility to the field of infection prevention with both the AIDS epidemic and the emergence of antibiotic-resistant microbes.3 Up to this point, IPs were traditionally performing surveillance; educating staff on the importance of hygiene, cleaning, and disinfection; and being the subject matter experts on processes to prevent infections. However, AIDS presented a risk of infection to the health care workers caring for the patients, and health care leaned upon IPs to determine best practices to keep workers safe.³ With the emergence of methicillin-resistant Staphylococcus aureus, IPs needed to determine screening protocols for new and colonized patients, cohorted patients, decontamination of health care workers identified as carriers, environmental disinfection, restriction of antibiotics, use of isolation precautions, and handwashing policies.³

The 1990s ended up being the “era of regulation” after The Joint Commission on the Accreditation of Health Care Organizations released a plan called Agenda for Change in 1987, which defined how an infection prevention program would be implemented.³ Additionally, guidelines directed at infection prevention programs were released, including isolation guidelines and guidelines for preventing and controlling nosocomial infections from the CDC and APIC’s guidelines on numerous topics such as hand washing and disinfection. Following the increased visibility and responsibilities of the IP in the regulation era, the University of Minnesota released the results from a study called the Delphi project, which stated that the ratio of IPs to beds should be 1:100.⁵

Between 2000 and 2020, infection control evolved into infection prevention, a significant change for the field. With the regulatory requirements, the new guidelines, and novel technology, the field of infection prevention took on a whole new life by preventing infections instead of controlling them.⁶ By 2010, the national data requirements with NHSN were significant, and electronic medical records were becoming increasingly popular, making IPs the data experts who needed to understand statistics, analytics, and information technology.⁶ As the field changed, so did the individuals performing the job. No longer were IPs nurses at the end of their careers who were going to coast into retirement. IP job descriptions were broadened to include other professional backgrounds, including public health and laboratory. Based on a national survey in 2019, the professional background of the IP workforce consisted of 65% nursing, 12% public health, 11% laboratory, and 12% other backgrounds.⁷ Additionally, many entry-level IPs were younger, being a part of Generation X or millennials, forcing the field to evolve even more. The younger generation was more tech-savvy and data-focused.

The evolution of infection prevention was driven by a change in focus and responsibility over the past 20 years. IPs were expected to know a significant amount of information about the hospital, including construction in a health care setting, the impacts of positive and negative airflow in critical and semicritical spaces, cleaning and disinfection of instruments, high-level disinfection of semicritical instruments, the impact of the environment on transmission of pathogens, state and federal regulations, employee health and exposures, and of course the chain of infection. IPs were expected to implement evidence-based practices and understand all the latest guidelines and recommendations to prevent infections. With these increasing responsibilities within this role, the recommendation for IP to bed ratio decreased again to 1:69.⁸

However, as infection prevention was becoming increasingly important in health care, the COVID-19 pandemic hit. The pandemic changed everything again in the field of infection prevention. IPs were suddenly thrown into the limelight as the experts, and instead of protecting the patients from the staff, they were developing protocols to protect the staff from the patients. Most traditional infection prevention practices were cast by the wayside, while IPs made decisions on the fly about what made the most sense during a chaotic time. Once the pandemic began to fade, the IPs were forced to refocus health care workers and remind them of life before COVID-19.

Now, as we enter the middle of the 2020s, the numerous responsibilities of the IP continue to change.

COVID-19 demonstrated the importance of infection prevention outside the acute care setting. IPs are needed in ambulatory clinics, dialysis centers, and day care and long-term care facilities, as well as on cruise ships. There are federal regulations on surveillance and infection prevention in long-term care facilities. Over 75 years ago, the IP’s role was that of a nurse identifying hospital-acquired infections, and it has evolved into being an expert on multiple subjects in multiple settings. Still, the goal will always remain the same—to prevent infections for vulnerable patients in a vulnerable setting.

References

1. Torriani F, Taplitz R. History of infection prevention and control. Infectious Diseases. 2010:76-85. doi:10.1016/B978-0-323-04579-7.00006-X

2. Smith PW, Watkins K, Hewlett A. Infection control through the ages. Am J Infect Control. 2012;40(1):35-42. doi:10.1016/j.ajic.2011.02.019

3. Garcia R, Barnard B, Kennedy V. The fifth evolutionary era in infection control: interventional epidemiology. Am J Infect Control. 2000;28(1):30-43. doi:10.1016/s0196-6553(00)90009-9

4. Haley RW, Quade D, Freeman HE, Bennett JV. Study on the efficacy of nosocomial infection control (SENIC Project): summary of study design. Am J Epidemiol. 1980;111(5):472-485. doi:10.1093/oxfordjournals.aje.a112928

5. O’Boyle C, Jackson M, Henly SJ. Staffing requirements for infection control programs in US health care facilities: Delphi project. Am J Infect Control. 2002;30(6):321-333. doi:10.1067/mic.2002.127930

6. Houston L, Nair S. Old school meets new school: the fusion of generations in infection prevention. Infection Control Today. May 30, 2022. Accessed February 21, 2024. https://www.infectioncontroltoday.com/view/old-meets-new-school-fusion-generations-infection-prevention

7. Gilmartin H, Reese SM, Smathers S. Recruitment and hiring practices in United States infection prevention and control departments: results of a national survey. Am J Infect Control. 2021;49(1):70-74. doi:10.1016/j.ajic.2020.07.024

8. Bartles R, Dickson A, Babade O. A systematic approach to quantifying infection prevention staffing and coverage needs. Am J Infect Control. 2018;46(5):487-491. doi:10.1016/j.ajic.2017.11.006