I’m both an infectious disease physician and a healthcare epidemiologist. I’ve prepared for a respiratory viral pandemic for my entire career — but there’s no way I could have anticipated the scale of the COVID-19 pandemic. As we reflect on the experiences of the past 2 years, we should look for ways to fortify our standard healthcare safety practices to be less open to disruption during the next crisis.
The pandemic brought to light vulnerabilities throughout our healthcare system, and it illuminated the need to incorporate redundancy and resilience in processes that prevent healthcare-associated infections and other threats to patient safety. Current programs often depend on a few infection prevention professionals rather than engaging the entire workforce in infection prevention and control efforts. Having just enough infection prevention staff to manage day-to-day operations leaves us woefully short in an emergency. Compounding these issues are workforce shortages across medicine. Even before COVID-19, experienced infection preventionists were retiring, leaving less seasoned teams that were already stretched thin. Extreme pressure and stress from the pandemic pushed people out of medicine, including healthcare epidemiology and infection control.
We need increased staffing levels that will allow us to respond to a crisis while simultaneously continuing routine infection prevention measures that keep patients safe. A recent report from the CDC’s National Health Safety Network highlighted increases in four types of healthcare-associated infections from 2019 to 2020: central line-associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated events, and methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections. Increased medical device and ventilator use for critically ill patients with COVID-19 explained some, but not all, of the rise in these infections. Notably, these increases occurred following years of steady decline in healthcare-associated infections.
An announcement that the U.S. Occupational Safety and Health Administration (OSHA) is increasing inspections of hospitals and nursing facilities to prepare for the potential emergence of new variants illustrates the urgency. To maintain preparedness, we should implement a variety of strategies now to strengthen our systems to be better prepared for the next COVID-19 surge or whatever crisis comes next. We need to set up frontline staff as partners in infection prevention efforts by building prevention practices and reminders into existing workflows, like those for daily inpatient rounds and patient transfer or discharge. We should develop a cadre of “extenders” within the infection prevention team to support more routine tasks such as data entry or calling floors to remove patients from isolation precautions as well as unit-based staff to work as liaisons at the local level to support initiatives and answer questions. These infection prevention extenders create capacity that can be rapidly flexed up or down to ensure that critical infection prevention activities can be maintained by the core expert team, who — as we’ve seen during COVID-19 — will also be needed to develop guidelines to keep patients and staff safe during emergencies.
Similarly, we need to develop updated, easily accessible tools to improve infection prevention education. Two such tools include Project Firstline from the CDC, and the Society for Healthcare Epidemiology of America’s (SHEA) Prevention Course in Healthcare-Associated Infection Knowledge and Control, known as Prevention CHKC. These tools provide the basics of infection prevention for frontline staff in a variety of formats (e.g., animated videos, slides, print materials). An added advantage of these brief educational tools is the ability to quickly train temporary staff used to expand clinical capacity during an emergency. During COVID-19 surges, many hospitals used travel nurses who may not have been as familiar with local infection prevention strategies. Leveraging national tools to standardize processes and infection prevention education within and between institutions smooths transitions to new and temporary staff and improves patient safety. If prevention strategies are time consuming and so customized that protocols can’t be learned in the middle of a crisis, then the risk of infection will be higher.
Finally, we can put technological solutions in place to support staff so that prevention of healthcare-associated infections does not depend solely on human factors. While these tools and information system solutions require a financial investment, they create a reliable system and open up staff time for other patient safety work that requires a trained clinical eye, such as evaluating a central line exit site, reviewing reasons for continued use of an indwelling urinary catheter, and developing guidelines around use of personal protective equipment (PPE).
Many view the waning of the most recent COVID-19 surge as a time to return to “normal” operations. To ignore the learnings of the pandemic so far would be a missed opportunity to reimagine our approach to patient safety. This is a crucial time to invest in infection prevention — in big picture thinking, in resources, and in personnel to protect our patients and staff now and in the future.
Sharon B. Wright, MD, MPH, is President of the Society for Healthcare Epidemiology of America and Chief Infection Prevention Officer at Beth Israel Lahey Health.