When Exhausted Infection Preventionists Saved the Day

Before the horror story known as the year 2020 disappears into the mist because nobody wants to think about it more than they have to, the uplifting story of just how important a role infection preventionists (IPs) played in staving off COVID-19 must be told. Tania Bubb, PhD, RN, CIC, intends to tell it. Bubb, the director of infection control at Memorial Sloan Kettering Cancer Center, today unveiled a study that she coauthored at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC). The study examines how IPs battled the COVID-19 pandemic to the point of exhaustion on one hand, and how on the other hand they were carried away by the exhilaration of being recognized by their fellow health care professionals for the expertise that they brought to the struggle. Bubb tells Infection Control Today® that IPs “may not have taken care of patients directly, but their policies, their procedures, their vigilance, and their enthusiasm for their jobs supported those who took care of the patients and laid the groundwork for how those who took care of the patients would remain safe.”

Infection Control Today®: This beat reporter found your study fascinating because it addresses the infection preventionist’s place in the hospital structure. How it may have changed because of COVID-19. Is that a fair assumption?

Tania Bubb, PhD, RN, CIC: That’s a fair assumption. We really wanted to just document the experience, noting that it was unprecedented. And we probably would never go through something like this again within our lifetime. We wanted to make sure that infection preventionists’ voices were heard during this time period.

ICT®: Do you see an interest in infection prevention growing as a possible career move for young people who may want to get into health care?

Bubb: That’s a hard question. I don’t think that I have seen that just yet. I’m not sure. I think it’s a fair question to evaluate how widely known now infection prevention and control as a profession is. And by whom it is known. I think we became popular within our own health care systems or health care facilities. I’m not sure how much media or outside external attention the field got during the pandemic. I think, rightly so, nurses and doctors were sort of the highlight of the pandemic, and on the frontline, and well-deserving of that [attention]. But there were a lot of other people behind the scenes, and the infection preventionist was definitely one of those professionals who was the mainstay of the pandemic and making things work, keeping the foundation running and alive.

ICT®: Did anything about your findings surprise you? Or was it kind of what you expected to find?

Bubb: I didn’t know what I expected to find. But I can tell you about some of the findings that we had. I’d like to note that my coauthor was [Janet P Haas PhD RN CIC]. She is a colleague and

Tania Bubb, PhD, RN, CIC

friend of mine. And we put our heads together during this time to do this. I think what we saw is that we got responses from about 16 U.S. states and three other countries. So, a pretty representative sample of IPs and our respondents comprised both IPs and IP directors or IPs in leadership roles. A small percentage of our respondents were MDs. That was very small. Not representative at all. And these were MDs that were within the infection prevention and control field. Our years of experience look like more … so folks who were very experienced greater than 10 years and then next up was folks who may have between six to 10 years of experience. So that comprises most of our respondents. And then we had a good sample of novices between one to three years [of experience]. About 19% of our respondents were between one to three years. So that was interesting. And the next thing we noted was that our sample really was representative of IPs in acute care systems. We know that many hospitals are part of the system now. They were IPs within systems. And then IPs within standalone acute care facilities. The next bunch were IPs in maternal health, community hospitals, oncology hospitals, long-term care and public health. And that was about 20% to 30% of our sample.

ICT®: Is there anything else that you found in your study that you want to relate to your fellow infection preventionists?

Bubb: Yes, for sure. I think we all know that we worked a lot of hours. Very early on our study was comprised of weekly surveys. March [2020] through May [2020], and then mid-May, we did it biweekly through mid-July [2020]. In the beginning of the study period, which was the beginning of the first wave of COVID-19 outside of China in the United States, we saw that folks were reporting working upwards of 70 hours per week. And that declined as we progressed through the study period into July where it became stabilized at about 50 hours or so per week. Still a lot of hours, but not as much as the initial phases, of course. We did note that stress level was high during the beginning phases of the study, as well, during the early stages March and April, then kind of evened out in May. I think there was this lull in May, where the average stress level seemed to plateau. And then in late June and early July, it spiked up a little bit and [we’re] unsure why. At that point, we had fewer and fewer people taking the survey so it might be just an anomaly of outlier here. I think that one of the things that I was surprised at—to address an earlier question you asked—was the level of invigoration and excitement at the level of teamwork and camaraderie. IPs really felt a high level of invigoration and excitement during the early phases of the study. That drastically declined as the latter stages of the study were reached. By mid-July, that was very low. And then, in terms of teamwork and camaraderie, IPs really felt a sense of—[among] themselves and [between] other medical professionals or health care workers—that they were on one team. That they were a part of this camaraderie that was uplifting and validating. And that was experienced throughout the whole study. Now, I think IPs really testify to feeling validated during the first part where they felt like, “Oh, people know us. They know that we exist. They know that we have expertise. That we have the knowledge and they’re consulting with us for recommendations.” And then on the other side of that there were … if you look at the narrative comments…. That’s where you get the nuances, really, in the narrative comments. There were some folks who felt unvalidated and felt like, “I was at the table, and I was being asked. But I wasn’t being included in the decision making.” There was some of that as well.

ICT®: Do you think that COVID-19 will make the ranks of infection preventionists grow?

Bubb: I think that people are more aware of infection prevention and control. I am not sure. And it is beyond what I know, to be true at this point, that people are now recognizing infection prevention as a career and as a substantive form of a career for them. I don’t know the answer to that question. I think it’s a great question to ask. Maybe APIC will ask it. Do a research study on that and ask that question.

ICT®: As you know, APIC is pushing to have states mandate that anybody who is called infection preventionist at a hospital or other health care facility actually be certified as such. Have the CIC after their name. Do you see that push getting stronger going forward?

Bubb: I do. And I think that CBIC [Certification Board of Infection Control and Epidemiology] also has responded to that call as well. I believe that CBIC has created layers of certification so that folks who are not ready for full CIC can be sort of like sub-certified or certified at a novice level. I think that there is value in certification. And I think that it is recognized within health care institutions that the expertise level of a certified infection preventionist is often greater than noncertified. But I think that there are challenges to that, too. I think that the access for certification is a privilege, right? That not every area in the United States geographically will be able to provide certification or have access to certification in the way that some other urban, major academic health systems might.

ICT®: Are you going to hire more infection preventionists personally?

Bubb: In terms of adding more fulltime personnel? What I’m thinking of is layering my department. I think that we have traditionally, as infection preventionists, believed that a department comprised of all infection preventionists and some kind of manager or supervisor…. And I what I’m seeing as a trend now is layering up positions. Creating some stratification for where there are the less experienced or folks who have aspirations of becoming an infection preventionist, but are not there yet. They might be starting out as a new grad. And I think that that is one of the ways to open the doors to novice and more people and more educational backgrounds in terms of where people are prepared to [practice] infection prevention.

ICT®: Looking back at it now, was there anything that could have been done help infection preventionists avoid the exhaustion that came with fighting the COVID-19 surges?

Bubb: Well, I don’t know that there was a way to avoid it. And that’s speaking overarchingly because I think that different health systems and different facilities were prepared at different levels based on their infrastructure, right? But if you’re talking about overarchingly in the nation, I’m not sure that I’m qualified to make that judgment. But I do agree with you that it was an exhausting situation, not just for health care professionals but for the whole system, infrastructure, economic, political, and otherwise.

ICT®: You mentioned that some of the answers to the questions in your survey were narratives. Can you paraphrase some of what you heard?

Bubb: Some things that we picked out just for the presentation at APIC were that—and I’ll tell you, a couple of things—were that basic IPC practices were validated. And so, some quotes that people said just very briefly. One quote: “Lots of people were shocked that they didn’t know how to properly remove PPE. I hope this knowledge will stay with them for a long time.” Another said: “We have never before seen such high compliance with hand hygiene.” We got a few comments like that. That hand hygiene rates had never been so high before as it is now. And then, another one—this is a little bit more outright—but, “Everyone and their mother cares about hand hygiene and PPE use.” Those were quotes related to infection prevention and control practices just being very important. Where that is something that we struggle with typically. Getting people to recognize the importance of these foundational infection prevention and control practices and recognizing them as valuable within their practice. We are not just the police slapping hands, but rather we are creating a safe environment for patients, staff, and visitors. Another theme that came out which everyone was well aware of was the PPE shortages. People were very torn with this. Infection preventionists were very torn and upset and frustrated by this. So, a few comments that illustrates this is that “PPE shortages were creating panic, hoarding and possible theft of PPE and [that was] adding to the crisis.” “We have to have our health care workers reuse gowns for their shifts. It is awful. This goes against all IPC basic principles. I’m so sad.” That was another comment. “Focus remained on PPE this week. There has certainly been heartburn over this experience and concern from the clinical teams on the safety of the process.” Those were just a few of the comments as they related to PPE shortages.

ICT®: Doctor Bubb is there something that I neglected to ask you that you think is pertinent that you want your fellow infection preventionists to know?

Bubb: I think that infection preventionists are really heroes of the COVID-19 pandemic. I think there are many heroes to celebrate, but specifically, because we’re talking about infection preventionists, I want to highlight the work that they have done, and the positions that they had to manage and the flexibility and the agility that they had to exhibit during the pandemic. Without real recognition of that and without real recognition of the support that they really provided to the entire hospital. They may not have taken care of patients directly, but their policies, their procedures, their vigilance, and their enthusiasm for their jobs supported those who took care of the patients and laid the groundwork for how those who took care of the patients would remain safe.

This interview has been edited for clarity and length.