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Saskia v. Popescu, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist with Phoenix Children's Hospital. During her work as an infection preventionist she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She is currently a PhD candidate in Biodefense at George Mason University where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in Infection Control.

Infection Prevention Gaps Found Across Critical Access Hospitals

JUN 18, 2018 | SASKIA V. POPESCU
One of the most fascinating studies presented at the 45th Annual Conference of the Association for Professionals in Infection Control and Epidemiology (APIC) delved into infection prevention and control gaps at critical access hospitals.

The infection prevention field is broad and as such, a hospital infection preventionist (IP) will cover everything from communicable disease surveillance to health care-associated infection investigations, to construction risk assessments and isolation rounding every day. Given the vast spectrum of things that fall under the infection prevention umbrella, it’s not surprising to see how diverse the gaps and failures can be.

Before considering infection prevention gaps, it is critical to address staffing of infection prevention and control programs within health care facilities.  A recent study found significant gaps in IP staffing in American hospitals and underscored that there should be 1 IP for every 69 beds for true oversight. IP rounding and surveillance is critical for identifying gaps in infection prevention processes that result in infections, whether they occur in patients or staff. This comes into play when discussing infection prevention and control failures and should be considered as the gaps in infection prevention are inherently tied to IP staffing and support. In many ways, not considering IP staffing and support in a discussion on infection prevention gaps is like discussing the full trash cans and environmental cleanliness gaps without discussing the staffing of the environmental services team and the capabilities that are bestowed upon them.

Such challenges exist even in the most prestigious hospitals and so it is unsurprising that critical access hospitals (CAHs) would be stressed in these areas as well. A CAH is a specific designation given by the Centers for Medicare & Medicaid  Services (CMS) aimed at “reducing the financial vulnerability of rural hospitals and improving access to health care by keeping essential services in rural communities.” CAHs are small and often have fewer than 25 inpatient beds. To meet CMS guidelines, these hospitals have to be a more than 35-mile drive from another hospital or more than a 15-mile drive from another hospital in a land area that has mountainous terrain or secondary roads. These hospitals provide vital health care to small communities that struggle to gain access to hospitals and CAHs can often act as a gateway to medical care that prevents health conditions from developing into serious, life-threatening events. 

The role and presence of infection prevention and control within CAHs, like longterm health facilities, has become a growing topic of concern. In such small hospitals, how do we ensure adequate infection prevention staffing or monitoring? If major hospitals are understaffed in their IPs, this likely translates to an even more challenging situation in CAHs. The reality is that it is common for the occupational health and infection prevention programs to be joined and run by a single nurse. 

Bearing these real concerns, a new study from researchers in Nebraska sought to identify the role of infection prevention in CAHs and potential gaps in their practices. Coordinated by public health officials, they reviewed infection prevention practices at 36 Nebraska hospitals utilizing assessment tools from the US Centers for Disease Control and Prevention (CDC) to identify gaps in processes.

The most significant gaps in their assessments were found to be in injection safety, central-line associated bloodstream infection prevention, and catheter-associated urinary tract infection prevention.

Although these were the hotspots for infection prevention gaps, the investigators ultimately found failures across the full domain of infection control practices.

According to the study results, CAHs lacked competency-based training programs and the ability to perform audits and provide feedback regarding infection prevention process failures. The hospitals in the study participated on a voluntary basis; however, they were able to receive visits from a team of certified IPs and public health officials to not only audit their processes but also to provide summaries of their findings and recommendations for fixing such failures.

Following their work, the team developed a resource website. They also underscored the importance of having a trained IP at the CAH and ensuring that the IP has the time to focus on activities such as rounding and promoting CDC-based practices. In all, the study underscored the importance of adequate IP staffing and training and that even the most rural hospitals benefit from the presence of an experienced IP.

I was fortunate to pose several questions to the lead study author, Margaret Drake, MT (ASCP), CIC, regarding the team’s findings. I was curious to learn if they found issues in IP knowledge or training (ie, identifying health care-associated infections (HAIs), surveillance, etc) or establishing infection prevention programs, and the role of administrative support. Drake noted that there weren’t “issues with identifying HAIs, but instead realizing or understanding how to do a risk assessment to set goals. Administrative support is there, but IPs need to know what and how to ask for it.”

She emphasized that IPs need to be “given the time and training to focus on infection control duties.” I asked what immediate infection prevention support should be given to these hospitals if resources are limited and Drake stated that “education and training” would be the most valuable.

These findings are not novel as staffing issues are problematic across the country in all types of hospital systems. The importance of having IPs within health care and ensuring they have access to training and the ability to focus on infection control activities—not just reporting tied to CMS reimbursement—is critical. IPs need time for activities such as education, rounding, antibiotic stewardship, and more.

This study supports the notion that not only should hospitals be ensuring proper staffing and support for infection prevention programs, but that significant gaps exist across CAHs. In the areas where CAHs are the only health care patients may access, it is vital that infection prevention processes be supported and followed. Ensuring adequate IP staffing and time are imperative for patient and health care worker safety. In infection prevention, we’re only as strong as our weakest link and this study has shown some damning weaknesses. 
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