COVID Fatigue and the Infection Preventionist

The need for infection preventionists has never been greater. What can hospitals and healthcare systems do to appropriately staff those positions?

By Graham Garrison

Linda Dickey, RN, MPH, CIC, FAPIC, Dickey Consulting LLC, has been an infection preventionist for more than 25 years. In that time, “we’ve never been in a situation where we have either reused or extended the use of personal protective equipment, certainly on the scale that we’ve had to do with COVID,” she said. Dickey is president-elect of the Association for Professionals in Infection Control and Prevention (APIC).

In the past, that reuse or extended use was simply not done as a fundamental tenant of infection prevention. Single-use items were used once and thrown away. Yet reuse and extended use was a situation that nearly every healthcare provider found themselves in amid the early days of the pandemic.

“We all realized when we ran into the supply chain issues that it made us think differently about how reserves are handled,” she said. “And it made us think more about the cost of that, because, obviously, there was warehouse space and holding a lot of supplies to consider, versus just-in-time inventory. COVID taught us all that we can’t always expect to have something readily available.”

Because there were so many interruptions in the supply chain, infection preventionists had to be nimble and work closely with supply chain partners. “We probably worked more closely with them than we ever did before,” Dickey said, whether it was examining personal protective equipment options, cleaning and disinfection options, or even options related to some types of services. “Not that we didn’t work closely with our supply chain partners before, but it made it abundantly clear that we are joined at the hip to try to solve these problems because they are quite vexing. COVID has been extremely challenging to our supply chain partners. It put them front and center in terms of trying to manage the availability of various types of products, hand in hand with maintaining safety.”

The beginning of the pandemic was extremely difficult for infection preventionists, Dickey said, because the guidance coming out was so fast, and so evolving. “Not only were people involved in epidemiology and infection prevention trying to calm fears and maintain patient care and answer questions, but we were doing it in the context of not necessarily having all the information that we would have known had the pandemic been further down the road. So, I think everyone in the whole world literally was working somewhat in a vacuum, learning about COVID-19, its transmission, what the options were for safe and effective care, and what the options were for actual treatment for these patients.”

Many infection preventionists worked around the clock, either extending workweek hours or fielding calls on the weekend. Dickey said for her, those extended hours started in late January and continued throughout the year. She didn’t have her first day off until Mother’s Day. “Our leadership was phenomenal, and our supply chain leader was over-the-top phenomenal and still is,” she said. “But we constantly had to find time to communicate with each other and develop communications that went out to the organization and make sure that we were all on the same page. That takes time, and thoughtfulness. And so, I think a lot of infection preventionists probably experienced that level of intensity for quite some time.”

Even off the clock, infection preventionists were still fielding questions from family or friends about COVID-19. “They were reaching out and asking, ‘Can you give us any more information?’ ‘What does this mean?’ ‘What should we be able to do that’s safe?’ So, you not only experienced the stress on the professional side of your life, but your personal side as well,” Dickey said. “It’s been a marathon.”

Extended fatigue

Infection preventionists have been planning and preparing for pandemics for years, said Robin Carver, RN, MSN, CIC, vice president, member engagement at Premier Inc. “I don’t think anybody could have been fully prepared for what we experienced, because even as we wrote plans, and participated in drills, you never know truly what’s going to hit you.”

Now with COVID cases on the decline, many infection preventionists are admitting that they are exhausted. Fatigue has set in.

“The impact to infection preventionists as a profession has been pretty profound over the last year,” said Carver. “We talk a lot about the front-line care providers, because they were the ones there day in and day out. But the IPs were also right there, day in and day out. And many of the IPs that I work with on a consistent basis have said, ‘I’m so exhausted. I have to be on call, or I have to be at the hospital 24 hours a day, seven days a week, because there are so many questions.’”

Indeed, hospitals and health systems have relied on their infection preventionists to answer an onslaught of questions. How do we isolate patients? Can we reuse this medical equipment? Can we co-room patients together, and what’s the risk associated with that? How do we get the right air filtration in place?

Infection preventionists have oversight into all those things in a hospital system, said Carver. “We think about them often as just the people that report hospital acquired infections or do hand hygiene policing. But they have to be experts across the board in things like ventilation, sterilization and disinfection of the environment and of medical devices. And the impact of the various organisms on different body systems.”

Infection preventionists as a profession are very close to retirement age. “The last survey that I saw indicated 55% of infection preventionists were at retirement age, which will leave us a huge gap,” Carver said.

In fact, Carver has worked with several health systems over the last few months who have said they need help finding an infection preventionist because they can’t adequately staff the position. “The reality is they’re just not out there. So, as we see people that have decided at the end of this pandemic that they can’t do this again, and don’t want to do this anymore, they’re either leaving the profession for other options or they’re retiring.”

Filling the gaps

The role of infection preventionist, and who has filled that role, is evolving. In the past, most infection preventionists started as nurses. They may have transferred from some other role into the infection prevention role. “For a long time, I think that was a qualifier of industry hiring practices,” Carver said.

Over the last decade, infection prevention has been moving into different disciplines. More people entering the role of infection preventionist may have an epidemiology, public health or a laboratory background. “I know a few IPs that are respiratory therapists by training,” Carver said. “We’re really trying to broaden what is the definition of an infection preventionist.”

A lot of health systems are also trying to tier their approach to infection prevention, Carver said. “If you think about it, just one part of what we do is surveillance – looking at lab results and determining in the clinical presentation, do they meet the definition of an infection? A lot of health systems are saying they can use a less experienced staff member for that.”

As a result, some health systems have created a role called an epi tech, which might be someone that’s not a nurse or does not have a higher-level clinical background, to fill the role of surveillance. The epi tech may transition up to an infection preventionist. “They’ve created tiers in their departments,” Carver said. “It also helps anytime you have that ladder of progression for people in our profession, certainly helps capture their attention.”

Salary is another lever for infection prevention. When hiring infection preventionists, infection prevention department leaders are competing against things like case management positions, where the employee can work 7 a.m. to 3 p.m., or they can work on the weekend and grab a weekend differential. But in today’s environment, infection preventionists have almost a 24/7 role. There are days they will have to be on call, late hours if an incident happens. They’re constantly having to figure out how to protect the staff or patients.

“So, if you’re going to choose, you’re probably going to choose the role that pays a little bit more, and you’re there 7 a.m. to 3 p.m. and then turn around and go home. The other factor a lot of organizations have been looking at is market salary. What do we need to do to really compete and get good talent in infection prevention roles?”

Infection prevention is a very specialized discipline. There is a lot of education and preparation that goes into it, Carver said. “When you have a shortage of infection preventionists, that means if you have an IP or two that’s left in your department, they of course have to pick up more. It means that they have to be pretty dedicated to the regulatory reporting that has to happen.”

CMS takes data from NHSN and calculates payments or penalties based on that in the value-based purchasing program. So, if a hospital is limited in the number of infection preventionists it has available, that means the reporting has to be their focus. “You have to make sure that the data gets in so you’re not penalized.”

A shortage of infection preventionists means the hospital may lose the monitoring that needs to happen in the clinical area. “You lose the expertise of that person being able to guide practice changes at the bedside,” Carver said. “You lose that person monitoring the environment to make sure that you know things are being cleaned appropriately, that operating rooms are being turned over correctly. You lose that oversight when you’re very limited and the only thing they can do is pay attention to the regulatory reporting programs. And how long are they going to stay in that position, if all they do is sit in the office and go through data and report it to the government?”

A pathway to more IPs

In late March, APIC announced their intention to create an infection prevention and control curriculum for colleges and universities. APIC’s IP Academic Pathway marks the first national effort to link undergraduate and graduate programs to the field of infection prevention and control, ultimately leading to certification in infection prevention and control.

“The pandemic has brought to light the tremendous need for trained infection preventionists in our nation’s healthcare facilities,” said APIC CEO Devin Jopp, EdD, MS. “While APIC has a robust competency model and other resources to support professionals already practicing in the field, a clear pathway into infection prevention and control careers does not currently exist for college and university students. Through IP Academic Pathway, APIC plans to create an intentional track for infection prevention certification and degree programs. This will help not only the healthcare field, but also industries like entertainment, hospitality, and travel, which are increasingly hiring infection preventionists.”

An APIC task force will develop the IP Academic Pathway core concepts, which will detail competencies needed to work successfully in infection prevention and control as outlined by the Certification Board of Infection Control and Epidemiology (CBIC). Once developed, the curriculum can be integrated into a higher education institution’s course of study through their undergraduate, graduate, and continuing education programs.

“Creating the IP Academic Pathway is a national imperative,” said Jopp. “As the leading organization in infection prevention and control, APIC is uniquely positioned to lead this initiative. APIC will be soliciting input from both the infection prevention and higher education communities and seeking university partners that are willing to help design and pilot the new program.”

Dickey said they are seeing the need for infection prevention expertise well beyond the acute healthcare setting. “COVID has shown very clearly that there’s a need for individuals who have this expertise in long-term care, home care and in other types of settings, even if it’s just to advise,” she said.

“There are even industries outside of healthcare that have asked, ‘How do you operationalize some of these infection prevention measures, and what does that look like for my business?’” Dickey continued. APIC wants to help educate people on the role of infection preventionists.  “So, I think that there’s actually quite a bright future and a strong future for people that are attracted to infection prevention.”