By Megan Headley
The COVID-19 pandemic has changed a great many things for healthcare, but it may have a particularly lasting impact on infection prevention programs. As the Society for Healthcare Epidemiology commented in a statement, “The pandemic has highlighted the need to strengthen infection prevention and antibiotic stewardship programs through additional personnel, resources, and training. These investments will support standard infection prevention and patient safety efforts while ensuring the capacity to prepare for future pandemics across the spectrum of healthcare.”
Many groups are laying out strategies for better mitigating disease transmission in future pandemics, ranging from the White House’s National COVID Preparedness Plan to the Rockefeller Foundation’s Roadmap for Living With COVID. Meanwhile, Dr. Tom Talbot, chief hospital epidemiologist at Vanderbilt University Medical Center (VUMC), encourages health systems to implement practices for securing more inclusive feedback, standardizing simple practices, and gauging success.
- Bring more stakeholders into infection prevention
Infection prevention has proven to be a task that impacts everyone in the healthcare facility. As a result, it’s critical to gather input from stakeholders who may not traditionally have been involved in defining infection risks, potential transmission routes, and safety protocols.
“A good example would be anesthesiologists, who may not have always been involved in thinking through infection prevention practices,” Talbot says. “But in doing activities like intubating patients, they are over the patient’s airway.” Thus, their input into the process has been valuable.
- Ensure continual PPE training and monitoring
While many health systems provide training on how to don and doff personal protective equipment (PPE), the COVID-19 pandemic has highlighted the importance of ongoing PPE training and monitoring.
In fact, a study from members of the University of North Carolina at Chapel Hill Medical Center’s infection prevention department, published in the November 2021 issue of the American Journal of Infection Control, demonstrated that PPE monitors can increase the efficacy of infection protection measures. During a 10-month period, the department admitted 1,427 COVID-19-positive patients within its high-risk containment zones and experienced only two possible healthcare-associated COVID-19 transmissions.
“The equipment can be uncomfortable and it’s hard to remember the steps … then you layer that on top of a very stressful patient care environment. It’s stressful to care for a COVID patient, especially early on when people were scared and nervous for their own health,” Talbot says. Ongoing monitoring is also important to safeguard the growing influx of temporary staff, who may not be familiar with the specifics of an organization’s safety protocols.
During COVID-19 surges at VUMC, “dofficers” provided basic training on PPE doffing but also traveled patient areas to guide staff members on best practices in real time. “Having that active, real-time, peer-to-peer reminder has been something really helpful for teams,” Talbot says.
- Standardize clean and dirty flow
The healthcare industry already has stringent practices in place for cleanliness, but the COVID-19 pandemic encouraged more members of the team, not just housekeeping, to step back and evaluate using a clean-to-dirty workflow. This process dictates moving from an area free of potential infection sources to areas with higher risk of being an infection source, and decontaminating oneself after working in potentially dirty areas.
“The overall process of flow for clean and dirty is something we took for granted, and we never really taught people,” Talbot says.
During the height of the pandemic, he points out, “People became very attuned to how this very contagious infection could spread and began thinking in ways that they wouldn’t have before.” It became common to stop and question whether a surface could be touched without heightening the risk of transmitting infection. While in many cases staff did not need to change their behavior, “it raised the need to monitor and track those kinds of things,” Talbot says.
- Get snapshots of success
As healthcare teams get a better sense of what needs to change to improve infection prevention, it’s valuable to have a metric for measuring success. Talbot suggests beginning with a monitoring program that already works for a facility, then thinking about new ways to scale it.
For VUMC, the best model proved to be an existing hand washing monitoring program. “We asked how we could take that system of routine monitoring and scale it differently,” Talbot says. “Maybe we can’t monitor as frequently as hand washing, but can we add things like: Are people wearing a mask? Are they wearing their mask correctly? Are they entering rooms with PPE? Are they transporting things correctly?”
With enough data from these snapshots, organizations can get a sense of how well they’re doing or how much they can improve, while leaving full audits to only the most high-risk activities.
- Aim for a balanced approach
Some of the most protective health measures carry their own risks and potential dangers. Arguably this has been one of the toughest lessons to come out of the pandemic.
Talbot equates some of the measures taken to putting a nurse in a full-body coverall to avoid needlestick injuries. “They’re totally covered, their skin is not exposed—but there are unintended consequences in terms of tolerability. That’s why we have hierarchies in control,” he says.
In terms of the pandemic, visitor restrictions have carried some notable tradeoffs. “Restricting all your visitors would prevent people from coming down with COVID, but it carried a negative impact on patients, not just psychologically but in other ways,” Talbot says. Research is only beginning to emerge suggesting that the absence of a patient advocate may have placed pediatric, pregnant, and other patients at higher risks of adverse events.
Now is the time for the infection prevention team to revisit their hierarchies of control and clarify protective layers based on risks identified during the COVID-19 pandemic.
“We need to rely on the science where we have it to say what we can safely do, but we’re going to have to balance things,” Talbot advises.
- Capture frontline feedback
Finally, Talbot advises that infection prevention teams and executive leaders should build in a feedback loop when making any changes to infection prevention programs.
“Everybody in practice has really been struck by how impactful it is to capture feedback from the real world on the challenges of implementing some of these practices, and the unintended consequences,” he says. “That really does inform some of the policymakers who may not be practicing in a hospital.”
Incorporating frontline feedback on the challenges of a strict lockdown approach could better balance these risks. “I think as we emerge out of COVID, that’s going to be really essential,” Talbot says.