Infection preventionists' experiences during the first nine months of the COVID-19 pandemic: Findings from focus groups conducted with Association of Professionals in Infection Control & Epidemiology (APIC) members

Infection preventionists' current and preferred training strategies and tools

BACKGROUND

Educating health care staff on infection prevention and control (IPC) is an essential role of infection preventionists (IPs), but the COVID-19 pandemic diverted resources away from IPC education.

METHODS

Association for Professionals in Infection Control and Epidemiology members were invited to complete an online survey from spring 2023 to assess current and preferred approaches and tools for training health care personnel on IPC. Vendors, retirees, APIC staff, or those not working in health care or public health were excluded.

RESULTS

In all, 2,432 IPs participated. IPs were more likely to report engaging in impromptu health care worker training (ie, just-in-time teaching and team huddles) versus planned educational activities (ie, learning modules, formal presentations, train-the-trainer, or simulation; Kruskal-Wallis = 288, P < .001). IPs' top preferred teaching methodologies included simulation or interactive activity, and their lowest preferred approach was independent learning modules. IPC training apps were frequently requested technology.

DISCUSSION

IPs ranked simulation as their top preferred teaching method; however, simulation was one of the least frequently used approaches. IP education should include strategies for delivering effective impromptu training and how to develop and implement interactive simulation-based education.

CONCLUSIONS

The expressed needs and preferences of IPs should be considered when developing IPC-related teaching and training tools.

Impact of the COVID-19 pandemic on infection control nurses: A path analysis of job stress, burnout, and turnover intention

BACKGROUND

A infection control nurse (ICN) has played substantial roles in infection control and epidemiology programs in hospitals to protect patients and coworkers during the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to explore the association between intention to leave in ICNs and job stress and burnout.

METHODS

This cross-sectional study was conducted among ICNs working in hospitals with ≥200 beds in South Korea from October 1 to 22, 2021. Variables included were related to general and job characteristics specific to COVID-19, as well as measures of job stress, burnout, and turnover intention for ICNs from previous studies. Path analysis was used to examine the relationships between job stress, burnout, turnover intention, and COVID-19-related work characteristics.

RESULTS

A total of 203 participants were included, of whom 95% were women. The results showed that work intensity in COVID-19 infection control was significantly associated with job stress (P<.001) and burnout (P = .035). Furthermore, job stress (P = .019) and burnout (P < .001) were positively correlated with turnover intention.

CONCLUSIONS

In a pandemic with emerging infectious diseases, strategies to reduce turnover among ICNs and ensure a sufficient workforce are crucial to reducing work intensity, considering the factors that affect job stress and burnout.

The association of nursing home infection preventionists' training and credentialing with resident COVID 19 deaths

BACKGROUND

Nursing home (NH) residents' vulnerability to COVID-19 underscores the importance of infection preventionists (IPs) within NHs. Our study aimed to determine whether training and credentialing of NH IPs were associated with resident COVID-19 deaths.

METHODS

This retrospective observational study utilized data from the Centers for Disease Control and Prevention's National Healthcare Safety Network NH COVID-19 Module and USAFacts, from May 2020 to February 2021, linked to a 2018 national NH survey. We categorized IP personnel training and credentialing into four groups: (1) LPN without training; (2) RN/advanced clinician without training; (3) LPN with training; and (4) RN/advanced clinician with training. Multivariable linear regression models of facility-level weekly deaths per 1000 residents as a function of facility characteristics, and county-level COVID-19 burden (i.e., weekly cases or deaths per 10,000 population) were estimated.

RESULTS

Our study included 857 NHs (weighted n = 14,840) across 489 counties and 50 states. Most NHs had over 100 beds, were for profit, part of chain organizations, and located in urban areas. Approximately 53% of NH IPs had infection control training and 82% were RNs/advanced clinicians. Compared with NHs employing IPs who were LPNs without training, NHs employing IPs who were RNs/advanced clinicians without training had lower weekly COVID-19 death rates (-1.04 deaths per 1000 residents; 95% CI -1.90, -0.18), and NHs employing IPs who were LPNs with training had lower COVID-19 death rates (-1.09 deaths per 1000 residents; 95% CI -2.07, -0.11) in adjusted models.

CONCLUSIONS

NHs with LPN IPs without training in infection control had higher death rates than NHs with LPN IPs with training in infection control, or NHs with RN/advanced clinicians in the IP role, regardless of IP training. IP training of RN/advanced clinician IPs was not associated with death rates. These findings suggest that efforts to standardize and improve IP training may be warranted.

The influence of hospital leadership support on burnout, psychological safety, and safety climate for US infection preventionists during the coronavirus disease 2019 (COVID-19) pandemic

OBJECTIVE

To explore infection preventionists' perceptions of hospital leadership support for infection prevention and control programs during the coronavirus disease 2019 (COVID-19) pandemic and relationships with individual perceptions of burnout, psychological safety, and safety climate.

DESIGN

Cross-sectional survey, administered April through December 2021.

SETTING

Random sample of non-federal acute-care hospitals in the United States.

PARTICIPANTS

Lead infection preventionists.

RESULTS

We received responses from 415 of 881 infection preventionists, representing a response rate of 47%. Among respondents, 64% reported very good to excellent hospital leadership support for their infection prevention and control program. However, 49% reported feeling burned out from their work. Also, ∼30% responded positively for all 7 psychological safety questions and were deemed to have "high psychological safety," and 76% responded positively to the 2 safety climate questions and were deemed to have a "high safety climate." Our results indicate an association between strong hospital leadership support and lower burnout (IRR, 0.61; 95% CI, 0.50-0.74), higher perceptions of psychological safety (IRR, 3.20; 95% CI, 2.00-5.10), and a corresponding 1.2 increase in safety climate on an ascending Likert scale from 1 to 10 (β, 1.21; 95% CI, 0.93-1.49).

CONCLUSIONS

Our national survey provides evidence that hospital leadership support may have helped infection preventionists avoid burnout and increase perceptions of psychological safety and safety climate during the COVID-19 pandemic. These findings aid in identifying factors that promote the well-being of infection preventionists and enhance the quality and safety of patient care.

Identifying a competency improvement strategy for infection prevention and control professionals: A rapid systematic review and cluster analysis

Remarkable progress has been made in infection prevention and control (IPC) in many countries, but some gaps emerged in the context of the coronavirus disease 2019 (COVID-19) pandemic. Core capabilities such as standard clinical precautions and tracing the source of infection were the focus of IPC in medical institutions during the pandemic. Therefore, the core competences of IPC professionals during the pandemic, and how these contributed to successful prevention and control of the epidemic, should be studied. To investigate, using a systematic review and cluster analysis, fundamental improvements in the competences of infection control and prevention professionals that may be emphasized in light of the COVID-19 pandemic. We searched the PubMed, Embase, Cochrane Library, Web of Science, CNKI, WanFang Data, and CBM databases for original articles exploring core competencies of IPC professionals during the COVID-19 pandemic (from January 1, 2020 to February 7, 2023). Weiciyun software was used for data extraction and the Donohue formula was followed to distinguish high-frequency technical terms. Cluster analysis was performed using the within-group linkage method and squared Euclidean distance as the metric to determine the priority competencies for development. We identified 46 studies with 29 high-frequency technical terms. The most common term was "infection prevention and control training" (184 times, 17.3%), followed by "hand hygiene" (172 times, 16.2%). "Infection prevention and control in clinical practice" was the most-reported core competency (367 times, 34.5%), followed by "microbiology and surveillance" (292 times, 27.5%). Cluster analysis showed two key areas of competence: Category 1 (program management and leadership, patient safety and occupational health, education and microbiology and surveillance) and Category 2 (IPC in clinical practice). During the COVID-19 pandemic, IPC program management and leadership, microbiology and surveillance, education, patient safety, and occupational health were the most important focus of development and should be given due consideration by IPC professionals.

Voices from frontline nurses on care quality and patient safety during COVID-19: An application of the Donabedian model

BACKGROUND

The COVID-19 pandemic has adversely impacted quality of care and patient safety. This study aimed to describe registered nurses' (RNs) perceptions on the impact of the COVID-19 pandemic on their ability to adhere to patient safety protocols using Donabedian's Health Care Quality model.

METHODS

In October 2020, a survey was conducted among all actively licensed RNs in New Jersey who provided direct patient care during the first peak of COVID-19.

RESULTS

Of 3,027 participants, 68% reported that the number of patients assigned impacted their ability to adhere to protocols. RNs identified a variety of organizational structures impacting adherence, including inadequate staffing, staff qualifications, and inadequate resources. Impacted processes included the inability to adhere to patient safety protocols and conduct comprehensive assessments and surveillance, the need for additional time spent on personal protective equipment and isolation policies, and difficulty maintaining isolation integrity; the need to prioritize and cluster care; and guidelines limiting personnel who could enter the room. Nurses attributed both adverse patient and staff outcomes to inadequate staffing and high patient acuity.

CONCLUSIONS

These findings highlight the need for health care organizations to support frontline nursing staff in adhering to patient safety and infection prevention and control protocols during times of crises. Infection preventionists have substantial contact with bedside nurses and should leverage their collegial relationships to promote patient safety.

Early coronavirus disease 2019 (COVID-19) pandemic effects on individual-level risk for healthcare-associated infections in hospitalized patients

OBJECTIVE

We compared the individual-level risk of hospital-onset infections with multidrug-resistant organisms (MDROs) in hospitalized patients prior to and during the coronavirus disease 2019 (COVID-19) pandemic. We also quantified the effects of COVID-19 diagnoses and intrahospital COVID-19 burden on subsequent MDRO infection risk.

DESIGN

Multicenter, retrospective, cohort study.

SETTING

Patient admission and clinical data were collected from 4 hospitals in the St. Louis area.

PATIENTS

Data were collected for patients admitted between January 2017 and August 2020, discharged no later than September 2020, and hospitalized ≥48 hours.

METHODS

Mixed-effects logistic regression models were fit to the data to estimate patients' individual-level risk of infection with MDRO pathogens of interest during hospitalization. Adjusted odds ratios were derived from regression models to quantify the effects of the COVID-19 period, COVID-19 diagnosis, and hospital-level COVID-19 burden on individual-level hospital-onset MDRO infection probabilities.

RESULTS

We calculated adjusted odds ratios for COVID-19-era hospital-onset Acinetobacter spp., P. aeruginosa and Enterobacteriaceae spp infections. Probabilities increased 2.64 (95% confidence interval [CI], 1.22-5.73) times, 1.44 (95% CI, 1.03-2.02) times, and 1.25 (95% CI, 1.00-1.58) times relative to the prepandemic period, respectively. COVID-19 patients were 4.18 (95% CI, 1.98-8.81) times more likely to acquire hospital-onset MDRO S. aureus infections.

CONCLUSIONS

Our results support the growing body of evidence indicating that the COVID-19 pandemic has increased hospital-onset MDRO infections.

Impacts of the COVID-19 pandemic on the infection prevention and control field: Findings from focus groups conducted with association for professionals in infection control & epidemiology (APIC) members in fall 2021

INTRODUCTION

Emergence of the Delta variant in 2021 changed the pandemic landscape and led to healthcare surges across the US, despite availability of COVID-19 vaccine. Anecdotal information indicated that the infection prevention and control (IPC) field was changing, but formal assessment was needed.

METHODS

Focus groups (6) were conducted with APIC members in November and December, 2021 to elicit infection preventionists' (IP) opinions changes to the IPC field due to the pandemic. Focus groups were audio recorded via Zoom and transcribed. Content analysis was used to identify major themes.

RESULTS

Ninety IPs participated. IPs described multiple changes to the IPC field during the pandemic, including being more involved in policy development, the challenge of transitioning back to routine IPC while still responding to COVID-19, increased need for IPs across practice settings, difficulties in recruiting and retaining IPs, presenteeism in healthcare, and extensive burnout. Participants suggested approaches to improve IPs' wellbeing.

CONCLUSIONS

The ongoing pandemic has brought significant changes to the IPC field, including a shortage of IPs just as the field is expanding rapidly. The continued overwhelming workload and stress due to the pandemic has resulted in burnout among IPs and the need for initiatives to improve their wellbeing.

Infection preventionists' experiences during the second year of the COVID-19 pandemic: Findings from focus groups conducted with association for professionals in infection control & epidemiology (APIC) members

INTRODUCTION

COVID-19 epidemiology changed dramatically in spring 2021 when vaccine became widely available and the Delta variant emerged. There was a need to identify current infection prevention challenges due to changing pandemic epidemiology.

METHODS

Six focus groups were conducted via Zoom with APIC members in November and December, 2021 to elicit infection preventionists' (IP) experiences with the COVID-19 pandemic after the Delta variant had emerged. Each focus group was audio recorded then transcribed verbatim. Content analysis was used to identify major themes.

RESULTS

In total, 90 IPs participated (average of 15 IPs per focus group). Participating IPs described multiple issues they have faced during the second year of the COVID-19 pandemic after the Delta variant emerged, including continuing challenges with personal protective equipment, changes in pandemic restrictions that caused confusion and pushback, the hope when vaccine first became available and then despair when there was more vaccine breakthrough than anticipated, staffing and medical supply shortages, overwhelming workloads, and anger towards health care personnel and IPs. However, IPs felt more valued by leadership, and reported greater internal collaboration and external coordination of care.

CONCLUSIONS

The second year of the pandemic brought ongoing and new challenges for IPs, but also better coordination of care. Strategic initiatives are needed to address the identified challenges, such as how to prioritize tasks when IPs are overwhelmed.

Associations among infection prevention professionals' mental/physical health, lifestyle behaviors, shift length, race, and workplace wellness support during COVID-19

BACKGROUND

COVID-19 added stress to infection prevention professionals' (IPs) work-life that may have impacted their well-being. This study aimed to describe IPs' mental and physical health and lifestyle behaviors during the pandemic and their associations with IP role, perceived worksite wellness support, shift length, and race and/or ethnicity.

METHODS

A random sample of Association for Professionals in Infection Control and Epidemiology members (6,000) were emailed a survey assessing mental and physical well-being, lifestyle behaviors, and perceived worksite wellness support.

RESULTS

A total of 926 IPs responded (15% response rate). Few met guidelines for sleep (34.1%), physical activity (18.8%), and fruit and vegetable consumption (7.3%). Rates of depression, anxiety, and burnout were 21.5%, 29.8%, and 65%. Front line and practicing IPs and IP administrators and directors had more negative mental health impacts than IPs in other roles. IPs with organizational wellness support were less likely to report negative COVID-19 impacts. IPs working 9-11+ hours/day were more likely to report worsening physical and mental health due to COVID-19. There were no significant differences in odds of negative COVID-19 impacts on lifestyle behaviors between white and racial and ethnically diverse IPs.

CONCLUSIONS

IPs who worked shorter shifts and had more organizational wellness support had better well-being outcomes. Organizations must fix system issues that result in poor health and invest in workforce wellness.

Barriers and Facilitators to the Use of Personal Protective Equipment in Long-Term Care: A Scoping Review

OBJECTIVE

To review existing literature evaluating barriers and facilitators to the use of personal protective equipment (PPE) by health care workers in long-term care (LTC).

DESIGN

Scoping review.

SETTING AND PARTICIPANTS

Health care workers in LTC settings.

METHODS

Several online databases were searched and a gray literature search was conducted. Study inclusion criteria were (1) conducted in nursing homes or LTC settings, (2) focused on LTC health care workers as the study population, and (3) identified barriers and/or facilitators to PPE use. The Theoretical Domains Framework (TDF), which assesses barriers to implementation across 14 behavioral change domains, was used to extract and organize data about barriers and facilitators to appropriate use of PPE from the included studies.

RESULTS

A total of 5216 references were screened for eligibility and 10 studies were included in this review. Eight of the 10 studies were conducted during the COVID-19 pandemic. Several barriers and facilitators to PPE use were identified. The most common TDF domain identified was environmental context and resources, which was observed in 9 of the 10 studies. Common barriers to PPE use included supply issues (n = 7 studies), the cost of acquisition (n = 3 studies), unclear guidelines on appropriate use of PPE (n = 2 studies), difficulty providing care (n = 2 studies), and anxiety about frightening patients (n = 2 studies). Having PPE readily available facilitated the use of PPE (n = 2 studies).

CONCLUSIONS AND IMPLICATIONS

Further research is necessary to identify barriers and facilitators more extensively across behavior change domains to develop effective strategies to improve PPE use and prevent infection transmission within LTC.

State of infection prevention and control in nonacute care US settings: 2020 APIC MegaSurvey

BACKGROUND

Strengthening infection prevention and control programs in nonacute care settings is a national priority. Efforts require thorough and ongoing appraisal of organizational structures, human resources including personnel training and competencies, system challenges and adaptive strategies implemented. Assessment of those in infection preventionist (IP) roles outside of the acute care setting is necessary to capture ongoing changes and challenges in the IP profession.

METHODS

This cross-sectional study utilized data derived from the 2020 APIC MegaSurvey and applied descriptive and bivariate analyses to describe the state of infection prevention and control programs and personnel across nonacute clinical settings in the United States.

RESULTS

Of 1,991 respondents, 57% of frontline IPs or administration/director IPs (1,051) indicated working in 1 or more nonacute care clinical settings. Of these, 33% (343) worked exclusively in only 1 type of nonacute care setting. Consistent with findings from the 2015 APIC MegaSurvey, IPs employed in nonacute care settings are a homogenous group with 88% of respondents indicating they are white, non-Hispanic (88%), female (94%), with nursing as their primary discipline (95%). A notable change in the proportion of time spent on health care-associated infection (HAI) activities in general was found, with a 31% decrease in reported time spent compared to respondents from the 2015 survey. Nearly half (47%) of respondents reported an annual salary of $50,000-$80,000; only 35% of respondents reported they were satisfied with their overall compensation. More than half (57%) of respondents reported having 5 or less years' experience in IPC and the majority, 82% reported they expected to be working in the IP profession in the next 5 years.

CONCLUSIONS

The majority of IPs in nonacute care settings also worked in acute care. Of those who exclusively worked in nonacute care settings, they were predominately female, white, and had an educational background in nursing. A decrease in time spent on HAI activities was noted compared to respondents in 2015. Although the 2020 APIC MegaSurvey captured information previously not assessed in 2015, further studies are necessary to more robustly characterize the IP profession in nonacute care settings. Enhancements to current resources and services provided by APIC may serve to fill gaps in nonacute care settings related to gaining experience in research, general expertise, advocacy, and diversity.

Emergent themes from a quality improvement programme for CLABSI/CAUTI prevention in ICUs amid the COVID-19 pandemic

Objectives

Healthcare-associated infection (HAI) prevention has been difficult for healthcare providers to maintain during the COVID-19 pandemic. This study summarises themes for maintaining infection prevention activities learnt from the implementation of a quality improvement (QI) programme during the pandemic.

Methods

We conducted qualitative analysis of participants’ semistructured exit interviews, self-assessments on HAI prevention activities, participant-created action plans, chat-box discussions during webinars and informal correspondence.

Setting

Intensive care units (ICUs) with elevated rates of central line-associated bloodstream infections (CLABSI) and/or catheter-associated urinary tract infections (CAUTI) participating in the Agency for Healthcare Research and Quality Safety Programme for ICUs: Preventing CLABSI and CAUTI.

Results

Forty-nine ICU teams who participated in the programme between December 2019 and April 2021 found ways to maintain activities such as daily huddles, multidisciplinary rounds, and central line and indwelling urinary catheter monitoring despite barriers, including staff turnover, a lack of time, staff fatigue and pandemic-related guidelines limiting providers’ time around patients. We use four themes to summarise the ICU teams’ adaptations that allowed them to sustain infection prevention activities: (1) Units had CLABSI and CAUTI prevention teams, policies and practices established prior to the pandemic; (2) Units were flexible in their implementation of those policies and practices; (3) Units maintained consistent buy-in for and engagement in HAI prevention activities among both leadership and care teams throughout the pandemic and (4) Units looked to learn from other units in their facility and beyond.

Conclusions

Future shocks such as the pandemic must be anticipated, and the healthcare system must be resilient to the resulting disruptions to HAI prevention activities. This study encountered four themes for successful maintenance of infection prevention activities during the current pandemic: the value of a pre-existing infection prevention infrastructure; a flexibility in approach; broad buy-in for maintaining QI programmes and the facilitation of idea-sharing.

Challenges in managing, sustaining, and assessing closed point of dispensing sites: Findings from a qualitative study

Most U.S. public health agencies rely upon closed points of dispensing (PODs) to aid in medical countermeasure (MCM) distribution. However, few studies have focused on how to assess closed POD preparedness and none have examined best practices for managing sites once they have been recruited. This study involved qualitative interviews with U.S. disaster planners to elucidate their approaches and challenges to managing, sustaining, and assessing existing closed POD sites. In all, 16 disaster planners participated. Common management practices included frequent communication with sites, providing formal and informal training, and assisting with POD exercises. Very few jurisdictions reported doing formal assessments of closed POD sites. The largest challenges identified were staff turnover and keeping sites engaged, sometimes leading to sites voluntarily withdrawing or needing to be removed from being a closed POD. Frequent communication and building partnerships with closed POD site personnel were recommended to maintain and sustain existing sites. Formal and informal assessments will provide assurance of deployment readiness. Closed POD management is a challenging, but essential process to ensure readiness to deploy. Practices outlined by this study can be implemented to enhance closed POD network management at other jurisdictions. This should increase the ability to distribute MCMs rapidly during a future event, contributing to stronger community resilience. Public health officials should continue expanding and improving closed POD networks to enable MCM delivery and minimize morbidity and mortality related to mass casualty events.

Rising from the pandemic ashes: Reflections on burnout and resiliency from the infection prevention and antimicrobial stewardship workforce

Hospital epidemiologists, infection preventionists, and antimicrobial stewards are integral to the pandemic workforce. However, regardless of pandemic surge or postsurge conditions, their workload remains high due to constant vigilance for new variants, emerging data, and evolving public health guidance. We describe the factors that have led to burnout and suggest strategies to enhance resilience.

Impact of COVID-19 on an infection prevention and control program, Iowa 2020-2021

Background

The COVID-19 pandemic has affected infection prevention and control (IPC) programs worldwide. We evaluated the impact of COVID-19 on the University of Iowa Hospitals & Clinics IPC program by measuring the volume of calls to the program, changes in healthcare-associated infection rates, and team member perceptions.

Methods

We retrieved the IPC call log and healthcare-associated infection trends for 2018-2020. We defined 2 periods: pre-COVID-19 (2018-2019) and COVID-19 (January-December 2020). We also conducted one-on-one interviews and focus group interviews with members of the IPC program and describe changes in their working conditions during the COVID-19 period.

Results

A total of 6,564 calls were recorded during 2018-2020. The pre-COVID-19 period had a median of 71 calls and/or month (range: 50-119). During the COVID-19 period, the median call volume increased to 368/month (range: 149-829), and most calls were related to isolation precautions (50%). During the COVID-19 period, the central line-associated bloodstream infection incidence increased significantly. Infection preventionists reported that the ambiguity and conflicting guidance during the pandemic were major challenges.

Conclusions

Our IPC program experienced a 500% increase in consultation requests. Planning for future bio-emergencies should include creative strategies to increase response capacity within IPC programs.