Old Meets New School: The Fusion of Generations in Infection Prevention

How do the veteran and the novice infection preventionists work together in the present climate? What do they think are their strengths and their differences as they combine their knowledge in the health care field? Infection Control Today® asked a veteran and a novice to find out.

The hospital discipline of infection control was established in the 1950s¹Since then, the specialty requirements and duties have gone through many changes. Infection Control Today® asked 2 infection preventionists—a veteran and a novice—about the changes they have seen in the profession and how infection preventionists of different experience levels view the profession and each other.

The Veteran—Technology Reshapes the Profession

By LaTitia Houston, MPH, BSN, RN, MT, CIC

As an infection preventionist (IP) during the "digital transition age," I have seen many changes and uncertainties introduced. IP staff used to be comprised mainly of nurses who were no longer at the bedside, and in the beginning of my career around 20 years ago, local and national government required little detailed reporting. The clinical staff—nurses and physicians alike—were confident in the care provided despite any health care–acquired infections (HAIs) that patients developed. Finally, the patients were satisfied to have been successfully treated with few complications.

But the birth of technology changed the face of infection prevention by requiring the demographics of the profession to change. In the past, nursing staff who were ready to exit the bedside and wanted to coast out of the clinical life were replaced with nonclinical staff eager to provide statistics on performance of the nursing staff.

Once I entered the field of IP around 2012, national data requirements were robust, paper charts were fading, and electronic medical records were becoming the new norm. Health care organizations began requesting detailed reporting of not only the safety of patients, but also the quality of care they were receiving. My nursing skills and knowledge were still a plus, but these changes required more. IP now required staff who could handle statistics, analytics, and information technology.

Organizations took notice and acted, realizing the demand for infection prevention was increasing. The job descriptions were broadened to allow others with varying backgrounds to succeed as IPs. Nurses were always welcome, but now public health personnel, laboratory technicians, sanitary specialists, and other fields experts were entering the industry as IPs.

However, this merge was awkward at first. Nursing staff were always considered clinical; everyone else was considered nonclinical and data driven. As a nurse with a master's degree in public health and 15 years of laboratory bench work, and now an IP, I was able to see all sides. My public health colleagues were able to calculate, format reports from trends, and identify gaps in surveillance data. They were able to communicate these gaps to their laboratory colleagues, who were able to speak on the susceptibility and origin of microbes. And this information was helpful for the nursing staff to visualize how transmission occurred.

This transition would not have happened if medicine did not become digitized. The organizations' acknowledgement brought the boosting of skills to infection prevention and also allowed the implementation of new initiatives, closing the electronic gaps within infection prevention. We all became experts, "superusers and trainers," with electronic medical record systems. The CDC² also implemented annual training³ on how to report and identify infections that were required for reporting, and local and state governments visited or provided webinars or on-site courses pertaining to electronic data reporting of communicable diseases.

Among the many things that changed during the fusion of generations in IP, the introduction of technology stands out the most. Before this transition, the local and national governments required little reporting.

The days of lab results found on the printer the next morning and faxing information to the state and local governments are now things of the past. We now send scripted emails or fax directly from the electronic medical records to the different governing bodies. The introduction of electronic medical records and data-mining programs was the beginning of where we are today.

This change started a chain reaction. IP nurses quoting evidence-based practice was no longer a statement; it was now able to be measured. Reports can be generated to capture the reason a patient was admitted, what happened during the time of the admission, surgeries, procedures, laboratory results, and discharge information. IP, clinical and nonclinical, validate and communicate whether evidence-based practices were implemented during patient care.

Before 20124, infection data reporting was voluntary for all hospitals nationally. Required infections were reported to the state and local governments, such as sexually transmitted diseases and hepatitis. The infection data were not related to the performance of care. Hospital staff were educated on the basics of hand hygiene and environmental cleanliness. The information provided was about communicable diseases and diseases within the surrounding community, and then these data were sent on a spreadsheet or a laboratory report by fax to the state and local governments. This was the life of an IP.

The initial transition was not very receptive to that nurse coasting from bedside to easy exit. Being an IP now required nurses to monitor the practices of their previous coworkers. Gone were the days of educating peers voluntarily on how infections from one patient affected another patient or how a patient who was admitted to the hospital for a broken leg did not get a urinary tract infection "just because"; IPs were now required to educate, observe, and validate evidence-based practices.

By 2015, many states required hospitals to report communicable diseases, and the federal government, along with state and local governments, required hospitals to report HAIs to the CDC's National Healthcare Safety Network.⁵ Technology enabled efficient capture of these data.

IPs were asked to not only know how to prevent infections, but also to know technology and how to present the data and report the data to the different entities. This change, again, was a challenge for those IPs who were from the bedside. But this opened the doors of infection prevention to public health and laboratory staff.

As Rebecca Leach, MPH, BSN, RN, CIC said in her article⁶ for Infection Control Today^®, "Over time, the tracking of HAIs became more regulated. State governments were passing legislation mandating public reporting of select HAIs, thereby forcing IP programs to focus efforts on those particular HAIs that were publicly reported.

The new face of infection prevention is still being molded. Currently, there are more demands from the government⁷, which require more data, more prevention knowledge, and always the improvement of patient care. Organizations will continue to review the needs required to meet these constant demands, and infection prevention requires a multidisciplinary staff for it to be successful.

The Novice—Positive Collaboration Around New Ideas

By Sashi Nair, MBBS

I am coming from the perspective of someone who is new to the field or learning. People like me—internal medicine residents working in the intensive care unit or the emergency department—were on the front lines during the COVID-19 pandemic.

My peers and I have a firsthand perspective on what something like COVID-19 can do to the health care system, having seen the tsunami it caused, how important infection control is, and how dangerous infection control gone wrong can be if we do not get things right. The new generation of infection preventionists (IPs) bring that perspective and voice to the table, and people, at least during my training, have been receptive to both. Being extra careful is important for everyone—our patients, frontline workers, other people involved in patient care, hospital staff, and providers.

The other thing about the newer generation of IPs is that we question older literature and demand that benefits be shown for certain interventions like contact isolation, contact gowns, etc; we also question the old guidelines and verify that there are benefits to patients.

Overall, I have not encountered much pushback from the older generation of IPs. In fact, people often welcome new perspectives—for example, newer data showing unnecessary isolation leads to worse patient outcomes, which was part of my residency training, and the perspective that isolations lead to worse outcomes, which is something that I have even seen.

Things evolved as my training progressed; for example, understanding the clinical perspective of "Does this patient actually have this disease?" is something that I have seen IPs work hard on—even involving clinicians if they're not physician IPs—to help sort out the question. Questioning has only become more important with COVID-19 and the complexities of trying to figure it out.

The science has changed so much in terms of a positive test not necessarily indicating a patient has a disease, and we have seen that with COVID-19: Patients can have very low-level viral shedding for months after the illness, and that does not necessarily mean they are infectious and need treated as such.

You need nuanced clinical decisions; you must look at the patient as a whole. You must look at their symptoms and what is happening with them rather than not just saying, "This is what the patient has, so now we have to do this." I have seen nuanced clinical decision-making go beyond COVID-19 to infections like methicillin-resistant Staphylococcus aureus (MRSA); from institution to institution, what clinicians do varies, but the question is, "Do they actually have a wound that is purely related, or is it that they had a positive MRSA swab at some point 10 years ago?"—followed by making more nuanced decisions.

I have seen the process change. I have been trained to think, "Even if they do have MRSA, is this something that is infectious to other people? Does it need to be isolated?" Many people can have a trace positive but not need to be isolated.

If you have Clostridioides difficile, you need to think, "Does this patient have diarrhea? Does this patient even need to be tested for C difficile or isolated?" You also need to consider the hospital reimbursement side of things. I am learning more about hospital reimbursement as I get through training, and that pressure to accurately classify and diagnose patients is even more intense when there is a financial penalty for misclassifying someone.

There is mixed literature for MRSA around whether you need to wear a contact gown. In some hospitals like where I did my residency, enough literature exists to make health care workers (HCWs) comfortable to say that for people with MRSA, if no pus is coming out the wound, you do not need to wear a gown because it does not help anything, and the gown is an environmental cost. Seeing HCWs with a contact gown is stigmatizing to the patient, and it decreases the amount of time that physicians and nurses spend in the room with the patient. The risks outweigh the benefits of isolation at that point.

The holistic approach is something that I was glad to see and that I hope to see more of in the future. Everyone I have encountered, at least on the clinical side or the physician-led scientists, is very happy to embrace new ideas, including holistic ones; the data were not there in the past to back up holistic approaches. For example, today less is more in terms of isolation (or isolating when only clinically relevant). The science also was not there in terms of more accurate testing for viral pathogens, and nor was polymerase chain reaction testing that has exploded. As that science has started to catch up, everyone is really excited about making infection prevention and control more precise.

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. Infection Prevention and Control Training for Healthcare Professionals. Centers for Disease Control and Prevention. March 7, 2019. Accessed May 1, 2022. https://www.cdc.gov/infectioncontrol/training/infection-control.html

3. CDC/STRIVE Infection Control Training. Centers for Disease Control and Prevention. September 22, 2021. Accessed May 1, 2022. https://www.cdc.gov/infectioncontrol/training/strive.html

4. Srinath D, Stone PW. State-mandated reporting of health care-associated infections in the United States: trends over time. Am J Med Qual. 2015;30(5):417-424. doi:10.1177/1062860614540200

5. States with HAI Reporting Mandates. Centers for Disease Control and Prevention. June 29, 2021. Accessed May 1, 2022. https://www.cdc.gov/hai/state-based/required-to-report-hai-nhsn.html

6. Leach, R. Tracking of health care-acquired infections continues to evolve. Infection Control Today. October 8, 2020. Accessed May 1, 2022. https://www.infectioncontroltoday.com/view/tracking-of-healthcare-acquired-infections-continues-to-evolve

7. HAI National Action Plan. U.S. Department of Health & Human Services. Accessed May 1, 2022. https://www.hhs.gov/oidp/topics/health-care-associated-infections/hai-action-plan/index.html