At a press conference at the recent APIC 2023 conference in Orlando, FL, it became clear that much of this work comes as a result of the devastating effect of the pandemic on hospitals.
“We were not able to do all the things that we normally do — we really spent all of our time on just COVID-19,” said Pat Jackson, RN, APIC president, at a press conference that opened the conference.
Moreover, relatively routine healthcare-associated infections (HAIs) were more serious and prolonged in the severely ill COVID patients that swamped hospitals, she noted. The Centers for Disease Control and Prevention (CDC) has reported that HAIs and antibiotic-resistant infections increased dramatically during the pandemic.1,2 It is no surprise that APIC remains besieged on many fronts.
“I think the reality is we lost about 10 years of progress on HAIs, and we are still struggling,” said Devin Jopp, EdD, MS, CEO of APIC. “We are still seeing cases of COVID and long COVID, so it is still having effects on our country.”
We must bring infection preventionist (IP) staffing into the modern age, not just for COVID but to prevent all HAIs, Jopp said.
In the current practice of medicine and infection prevention, the old staffing ratios of one IP per 250 patient beds, or even one IP per 100 beds, are woefully out of date. Healthcare delivery has continued a complete metamorphosis since the research that led to those ratios, with the 250-bed ratio going back 50 years or so.
“We have done a lot of research and we are coming out with an [IP staffing] calculator that looks at multiple variables, like patient volume and complexity,” Jopp says. “How do we take all these components into effect in order to ensure we have the proper number of IPs?”
APIC will roll out a beta model of the calculator later this year, allowing IPs and others to project staffing estimates and work with the tool.
“Once we start collecting data into the calculator, we will start perfecting it,” Jopp continued. “While the first version will debut this year, we will have the final version of it by 2024. This is something our members are very tuned in to, especially as hospitals make decisions on staffing issues.”
After the instrument is thoroughly refined, APIC hopes IPs can use it in talking to administrators about staffing and that eventually it will be adopted by accrediting agencies.
“I think IPs can work with their leadership and try to help them understand how this is determined,” Jopp says. “[Explain] here [are] the data we used, and here are the variables. Also, we will eventually look at some of our HAI data. I think having quantitative data always helps. Our hope is that standard and accreditation bodies start using this in their determinations. I think there is an opportunity to educate and lead that initiative.”
‘I’m An IP; You’re Welcome’
On a considerably lighter note, APIC keynote speaker, Bertice Berry, PhD, sociologist and author, delivered an alternately hilarious and heartfelt keynote address. Exhibit A: When her first marriage was annulled in less than year, Berry said she penned a country song entitled, “If I’d Shot You Sooner I’d Be Out of Jail by Now.”
She then went off on a riff about some men being put off by Black women who enjoy country music, with one asking her, of all things, “Are you a lesbian?” She answered sarcastically, “Are you the alternative?”
Berry has been a stand-up comedian and has the impeccable timing to show for it. In addition to being a spiritual leader in her community of Savannah, GA — she led a church effort to sew masks when the pandemic began — Berry is a public and motivational speaker and the first person in her family to go to college. She graduated magna cum laude.
Her central message for IPs was to reclaim their narrative, to tell people what they do in no uncertain terms, and to empower others to do likewise. “When people ask you what you do, say, ‘I’m an IP; you’re welcome,’” she said.
At times comical and dead serious, Berry’s style was perhaps best captured when she channeled the great South African leader Nelson Mandela in an impression of his own voice: “It’s not that we are powerless; it’s that we are powerful beyond measure. It is our light, not our darkness, that we are afraid of.”
The message was clear. IPs must move out of the darkness of the pandemic — and, to some degree, their own past — to empower their programs and take the field to the next level. Saying an IP saved her daughter’s life when a downward cascade of health conditions resulted in a line infection, Berry added that all the prevention work IPs do day-in and day-out “makes the world a better place.”
But she added that she thinks IPs must reconnect to their purpose — realize they have a “calling,” not a job.
Own this, she emphasized, don’t let yourself become victim to the “imposter syndrome” — that old psychological trap where everyone thinks highly of a person who herself is full of doubt and negative self-talk.
“No matter what you’re going through you have the power to change the outcome,” she told APIC attendees. “I‘ve been doing this for 30 years, and there has never been an audience that [that statement] applies to more than today. You have the ability to change outcomes that no one else even sees coming. You have to live it — because this is your purpose.”
Berry closed with a gospel song, showing her full repertoire, after saying IPs are like “the Holy Spirit. You don’t see them, but you can feel their power.”
This silent presence also raises the risk of falling into anonymity when everything is on the table in post-pandemic healthcare. At one point Berry summed it up bluntly: “We’ve just been through a pandemic, and people still don’t know what you do.”
The Long Shadow
Of course, IPs now are becoming clinical leaders and directing hospital-wide infection prevention efforts, but the field has not yet completely shaken the shadow of its obscure beginning reporting “nosocomial” infections. As Robert Haley, MD, director of the landmark CDC Study on the Efficacy of Nosocomial Infection Control (SENIC) project has explained, the agency knew when they started collecting data in the 1970s that hospitals would not be eager to report patient “infections.” The intentionally arcane term “nosocomial” was used so hospitals would provide the data the CDC needed to define the scope of the problem. (See Hospital Infection Control & Prevention, February 2023.)
IPs have come a long way from those days of collecting infection data for the CDC but, to Berry’s point, there still is a lot of work to do, Jackson said.
“We need to do a better job of training IPs as leaders,” Jackson said. “I think a lot of people thought of themselves then as data collectors who then give the data to someone else. What we are trying to empower our members with now is that you are the person [who] can create change in the hospital. You can drive change and be a leader. We are working on a lot of content on that right now.”
Another possible obstacle to this is that raising the profile of IPs as patient champions who prevent infections may be anathema to hospital marketing and risk managers because it opens up issues of patient harm and liability.
Still, it is a favorable sign that there seem to be fewer newspaper exposés about a “hidden” epidemic of infections in hospitals that are some kind of open “secret.” To one of these tabloid-like reports, veteran IP Patti Grant, RN, BSN, MS, CIC, a former APIC president, once said: “It is not hidden. APIC is not a secret society.”
Indeed, in the present situation, the pandemic has raised global awareness that infectious diseases can beset communities and hospitals and must be prevented because lives are at stake. But has the power of prevention taken on a new appreciation or is infection control still branded as a non-revenue-generating department? If it is the latter, then even if IPs drive infections down to nil, they run the risk of becoming all the more invisible to the powers that be. “Zero is not an exciting number,” Jopp said.
But individual IPs have done a remarkable job in recent years in showing how a prevented infection goes directly to the bottom line. In an example from a recent APIC webinar, IPs led a project that dramatically reduced central line-associated bloodstream infections (CLABSIs) by 70%, saving their hospital system more than $1 million in prevented infections. More importantly, patient suffering and deaths were greatly reduced because more than two-thirds of these high-mortality infections never occurred. (See Hospital Infection Control & Prevention, May 2023.)
APIC is working on a white paper to emphasize this aspect, trying to make the case to hospital boards that an adequately staffed and well-compensated infection prevention department is one of the best investments they can make in patient safety. Long-term care (LTC) is a different story.
Disaster and Indecision
It may seem hard to believe after the decimation SARS-CoV-2 caused in nursing homes, but making the case for investment in infection prevention remains a tough sell in LTC. (See “APIC Calls on Congress to Act.”) APIC has been pushing for a full-time, dedicated IP in LTC for years, largely to no avail. Then SARS-CoV-2 devastated nursing homes.
At a recent Congressional hearing, David Grabowski, PhD, a professor of healthcare policy at Harvard Medical School, testified that “COVID has completely devastated nursing homes in the U.S. After accounting for the gap in federal data at the start of the pandemic, there have been over 1.6 million COVID cases among nursing home residents, leading to roughly 176,000 COVID-related fatalities. For comparative purposes, this is equivalent to 12% of all residents living in a nursing home at the start of the pandemic.”3
In any case, the principle and enduring argument in LTC is that infection control is expensive, with its requirements for expertise and infrastructure.4 The question must be asked, briefly leaving aside basic morality and ethics: How much did 1.6 million COVID-19 infections and a double-digit mortality rate in LTC residents cost?
APIC plans call for the staff calculator eventually to include LTC, where the presence and duties of an IP have been somewhat opaquely defined by the Centers for Medicare and Medicaid Services (CMS).
The CMS states that “the requirement is [for LTC] to have at least a part-time IP,” which APIC feels is insufficient and commonly diluted by other job responsibilities.5 This historical pattern of job dilution is why APIC has insisted on a full-time nursing home IP with no ancillary duties, focused solely on preventing HAIs in residents and staff.
“There will be some fighting back on this, but to me it makes no sense that we are still talking about having IPs in nursing homes after the tragedy of COVID,” Jopp said.
The thought of having full time IPs — who did only infection control — in LTC before the pandemic hit raises one of those haunting unanswerable questions: How many lives could have been saved? Certainly, many IPs in hospitals saw their programs overrun, but did their best to minimize the mortality.
Beyond SARS-CoV-2, APIC stresses that the lack of strong infection prevention programs in nursing homes opens wide the gates for a variety of pathogens — including Candida auris and an emerging array of multidrug-resistant bacteria.6
“When you start looking at the numbers, we think there are between 1 and 3 million HAIs in [LTC] facilities,” Jopp said. “Why don’t we know? Because they don’t have to file a report. Why are they not able to have reporting and staffing requirements for infections in these facilities?”
Health Equity Fund Created
APIC has also been addressing the healthcare inequity exposed by the pandemic, including the deep fault lines revealed in ethnicity and poverty. Last year, APIC formed the Health Inequities and Disparities Taskforce, a formal committee that will explore areas such as possible racial and ethnic disparities in patients with HAIs. (See Hospital Infection Control & Prevention, November 2022.)
At the APIC 2023 conference, a major infection control outreach effort was announced to help isolated rural hospitals. This comes as part of the newly founded APIC Health Equity Fund, which will provide free IP resources to underserved U.S. communities.
This is an ambitious project with a long-term view of bringing in other types of healthcare settings, but it will begin with remote, rural “critical access” hospitals. Critical access hospitals are remote by definition — about 30 miles from another hospital and having no more than 25 acute care beds. As lifelines in rural communities, they have different rules for participation and reimbursement by the CMS and they often rely on transfer to full-service hospitals for severely ill patients.
“We have a big problem with health inequity; we know that isolated rural areas don’t have equal access to healthcare,” Jackson said. “Our idea is by creating this fund we can help these IPs, and secondarily improve infection prevention in their communities. Having been an APIC member for 29 years, we have never done something like this, where we have given so many resources to our members [who] really need it.”
The project is a joint effort — with the support of sponsors — by APIC, APIC Consulting Services, and the Certification Board of Infection Control and Epidemiology. The first three years will focus on critical access hospitals, which must apply and will be selected based on the merit of their application. Each hospital selected will receive:
• 150 hours of free infection prevention and control consulting services;
• free APIC memberships and chapter memberships for two years;
• two free subscriptions to the APIC Text for two years;
• two free certification prep courses;
• two free Associate-Infection Prevention and Control or Certification in Infection Control certification exams;
• access to the APIC Policies and Procedures Library for two years;
• two free APIC annual conference registrations for two years, including travel expenses;
• membership in APIC’s new Critical Access Hospital virtual network.
To that latter point, the idea is creating connectivity between these hospitals, both with each other and with APIC. This may prove as important as any aspect of the program, as such a virtual network could easily be expanded and provide peer-to-peer problem solving, camaraderie, and mentorship opportunities.
Each year, for three years, three critical access facilities will be awarded the APIC scholarship, so APIC is aiming for nine fully up-to-speed hospitals by December 2026. The total value of each scholarship is more than $50,000.
The application period for the critical access hospitals opens in late August, with a due date of Sept. 30, 2023. Awardees will be notified in October. “The plan is that we are really going to grow this fund, but this first initiative is this scholarship for IPs in critical access hospitals,” Jackson said. “We hope to add other things like long-term care and other initiatives.”
REFERENCES
- Lastinger LM, Alvarez CR, Kofman A, et al. Continued increases in the incidence of healthcare-associated infection (HAI) during the second year of the coronavirus disease 2019 (COVID-19) pandemic. Infect Control Hosp Epidemiol 2023;44:997-1001.
- Centers for Disease Control and Prevention. COVID-19: U.S. Impact on Antimicrobial Resistance. Special Report 2022. https://www.cdc.gov/drugresistance/pdf/covid19-impact-report-508.pdf
- Committee on Oversight and Accountability. Hearing wrap up: “Must-admit” COVID-19 nursing home mandates were deadly for elderly Americans, state officials responsible. Published May 18, 2023. https://oversight.house.gov/release/hearing-wrap-up-must-admit-covid-19-nursing-home-mandates-were-deadly-for-elderly-americans-state-officials-responsible%EF%BF%BC/
- Siddiqi Z. Costly endeavors: New era of nursing home infection control comes with high pricetag. Skilled Nursing News. Published May 8, 2023. https://skillednursingnews.com/2023/05/costly-endeavors-new-era-of-nursing-home-infection-control-comes-with-high-pricetag/
- Centers for Medicare and Medicaid Services. Updated guidance for nursing home resident health and safety. Published June 29, 2022. https://www.cms.gov/newsroom/fact-sheets/updated-guidance-nursing-home-resident-health-and-safety#:~:text=Infection%20Control%3A,the%20needs%20of%20the%20facility
- Association for Professionals in Infection Control and Epidemiology. APIC statement in response to GAO report titled “COVID-19 in nursing homes: Experts identified actions aimed at improving infection prevention and control.” Published March 29, 2023. https://apic.org/news/apic-statement-in-response-to-gao-report-titled-covid-19-in-nursing-homes-experts-identified-actions-aimed-at-improving-infection-prevention-and-control/
Although the prime mission of protecting patients and healthcare personnel remains the goal, the Association for Professionals in Infection Control and Epidemiology is undertaking an ambitious agenda of initiatives as part of a post-pandemic reassessment and reinvention.
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