ABSTRACT: Since the onset of the COVID-19 pandemic, the daily responsibilities of the Infection Prevention Department (IPD) have been exacerbated by heightened regulatory and licensing requirements, increasing demands from medical staff and patients, and an expanded scope of work. Consequently, infection preventionists (IPs) have struggled to find the bandwidth to effectively implement patient quality care improvement projects. The increased demand for infection prevention and control (IPAC) responsibilities has made it challenging to fill open IP positions. To address this need, a collaborative Modified Work Program (MWP) between the IPD and Human Resource Department at a National Cancer Institute-Designated Comprehensive Cancer Center has proven effective. Modified Staff for Infection Prevention (MSFIP) have been utilized to support IPD daily responsibilities with the potential development of future IPs.
Suwannee Srisatidnarakul, RN, MSN, CIC, CPHQ, HACP*
*Corresponding author
Suwannee Srisatidnarakul
Infection Prevention Department
City of Hope National Cancer Center
USA
ABSTRACT
Background: Since the onset of the COVID-19 pandemic, the daily responsibilities of the Infection Prevention Department (IPD) have been exacerbated by heightened regulatory and licensing requirements, increasing demands from medical staff and patients, and an expanded scope of work. Consequently, infection preventionists (IPs) have struggled to find the bandwidth to effectively implement patient quality care improvement projects. The increased demand for infection prevention and control (IPAC) responsibilities has made it challenging to fill open IP positions. To address this need, a collaborative Modified Work Program (MWP) between the IPD and Human Resource Department at a National Cancer Institute-Designated Comprehensive Cancer Center has proven effective. Modified Staff for Infection Prevention (MSFIP) have been utilized to support IPD daily responsibilities with the potential development of future IPs.
Methods: Injured staff were placed on modified duty by the MWP, and the IPD was contacted. An IP interviewed the MSFIP to design appropriate and accommodated responsibilities. Several tools were provided, including helpful guides, daily task lists, links, forms, agency contact information, and references. The MSFIP was granted temporary data security access to electronic medical records used by IPs. Initially, MSFIPs required orientation and shadowing by IPs. Later, MSFIP with longer recovery periods trained new MSFIP.
Results: Trained MSFIPs independently managed simple IP daily tasks, allowing IPs to continue and initiate quality improvement projects. Catheter-associated urinary tract infections remained low. All MSFIP expressed a better appreciation of IP work, and several expressed interest in becoming IPs, potentially addressing the replacement of retiring IPs.
Conclusion: A well-developed program for MSFIP offers several benefits. IPs should consider using MSFIPs if an MWP exists in their facility, or work on developing one in collaboration with their human resources department.
KEYWORDS
Modified, injury, infection preventionist, pandemic
INTRODUCTION
From the beginning of the COVID-19 pandemic, the responsibilities of Infection Preventionists (IPs) have increased, partly due to heightened regulatory and licensing requirements, growing demands from medical staff, patients, and an expanded scope of work. A survey by the Association for Professional in Infection Control and Epidemiology (APIC) in 2018 revealed that acute care hospitals in the United States with an inpatient census between 0-150 were typically staffed with only one IP (Pogorzelska-Maziarz et al., 2018). Findings from the APIC member focus groups conducted in November and December of 2021, indicated that the COVID-19 pandemic has generally exacerbated the responsibilities of IPs across hospitals. IPs have faced multiple changes and role expansions in addition to their routine and essential responsibilities, such as surveillance, outbreak response, education, mandatory meetings, and regulatory reporting on communicable diseases or hospital-acquired infection (HAI) data (Rebmann et al., 2023).
Another APIC survey revealed the need for increased IP staffing due to the evolving healthcare systems in both inpatient and outpatient settings, regulatory requirements, and the anticipated retirement of nearly 40% of current IPs (Gilmartin et al., 2021). Despite awareness of the growing challenges in fulfilling infection prevention and control (IPAC) responsibilities, there has not been any literature published on effective interventions to address IP recruitment and workload through task delegation.
The IPs at City of Hope National Medical Center (COH) leveraged the Human Resource Department Worker’s Compensation Modified Work Program (MWP) to establish a Modified Staff for Infection Prevention (MSFIP) program to assist with their workload. To explore its benefits, the IPs conducted an exploratory study aimed at answering two research questions:1) What is the impact of the MSFIP on reducing IPs’ exacerbated workload support? 2) What is the possibility of MSFIPs’ interest in becoming IPs through role exposure, thereby addressing the IP shortage? To the best of my knowledge, this is the first study of its kind to explore the possibility of the MSFIP program in addressing IPs’ needs.
The findings in the current study suggest that by utilizing MSFIP to conduct basic tasks, such as audits on hand hygiene, isolation practices, personal protective equipment use, and regulatory reporting provided IPs with ample time to focus on prevention
and control quality improvement responsibilities.
METHODS
Inclusion and exclusion criteria
The MSFIP provider’s note was used to determine the inclusion and exclusion criteria. The injured staff with no absolute
use of their hand and wrist were excluded from the study. Most of the restrictions included no lifting of heavy objects, no pulling or reaching – none of which were required to perform tasks in Infection Prevention Department (IPD). Additionally, various job activities in IPD, such as rounding, competency observation, and reviewing patient records could accommodate restrictions such as “no typing for more than 1 hour every
4 hours”. Most injured staff were effectively accommodated.
To prevent further injury, all MSFIP were instructed to stay within their assignments, strictly comply with the restrictions, take frequent breaks, and report any unusual or increased discomfort. Most of the accepted MSFIP were registered nurses (RNs) because they were the largest group sustaining injuries. More importantly, RNs required a smaller learning curve as they were familiar with many nursing metrics monitored by the IPD. Fifty-five RNs (n = 55) were included in this study.
The Human Resource MWP contacted the IPD for potential placement of a modified staff. Two factors contributed to the small sample size: limited computers and office spaces in the IPD, and the need for modified staff to provide support in other departments. Despite this, the IPD was able to maintain a constant flow of 1-3 MSFIP per day throughout the 24-month study period.
Study period and interventions
This observational study ran from March 2019 to February 2023. The study interventions included four main components: 1) developing processes and documents to aid the MSFIP in performing daily tasks; 2) ensuring accessibility to documents and reports for tasks completion; 3) creating a forum for collaboration and communication; and, 4) providing computers and workspace. Throughout the study period, the IPD had two empty offices with desktop computers.
The two main documents created to guide the orientation and workflow process were Duty Guide and Duty List. Examples of the MSFIP’s general duties included reporting communication diseases, patient and staff COVID-19 reporting, record keeping and filing, Candida auris surveillance, following up on send-out labs, hand hygiene audits and isolation rounds, daily need assessment of Foley catheter needs, collating data from the HAI case findings, and assisting IPs with other tasks
as needed.
The Duty Guide contained detailed information to assist MSFIP with completing their daily duties. This included regulatory agencies’ reporting links and related reporting forms, essential contact information for personnel, a list of the reportable communicable diseases, guidance on the lab interpretations (reportable/non-reportable), various surveillance forms, infection control risk assessment and risk mitigation compliance assessment forms, and components of central line and Foley catheter care bundles. The Duty Guide and Duty List were provided on the first day as part of the orientation process.
Data access
Accessibility to documents and reports were achieved through collaborating with the Information Technology (IT) Department.
This collaboration involved granting MSFIP temporary IP-level security access, converting necessary documents into shareable formats, and adding MSFIP to various distribution lists (DLs)
such as “Positive COVID-19 Employees” and “Contact Tracing”.
A communication and collaboration forum was created using the DL-MSFIP email. Additionally, Microsoft Teams was set for MSFIP to centralize documents and track completed and ongoing work. All IPs were included in the DL-MSFIP email and MSFIP Teams to facilitate communication efficiency, document accessibility, and follow-up on tasks and projects.
To maintain constant availability of MSFIP in the IPD, IPs contacted the Human Resource Worker’s Compensation MWP when an existing MSFIP was expected to return to full duty within two to three weeks. Since recovery times varied among the MSFIP due to different types of injuries, the MSFIP who were in IPD for
a longer period were able to train new MSFIP on simple tasks.
To ensure accuracy and quality of work, IPs continued to provide new MSFIP training on certain tasks such as hand hygiene audits and conducting rounds.
To promote job satisfaction, MSFIP were allowed to self-schedule to accommodate their personal needs (Wynendaele
et al., 2020).
RESULTS
Reduction in catheter-associated urinary tract infections
MSFIP efforts to support the reduction of HAIs were particularly effective in reducing catheter-associated urinary tract infections (CAUTIs). Alerting registered nurses to remove Foley catheters without appropriate criteria led to a decrease in the CAUTI Standardized Infection Ratio (SIR) from 0.79 in 2019 to 0.49 in
2021 (Figure 1). By 2023, the CAUTI SIR remained consistently
low at 0.458.
In addition to managing urinary catheter devices, MSFIP successfully implemented a hospital-wide central line bundle
audit in 2020 with minimal initial guidance. The results were forwarded to the Nursing Department to address the findings.
In 2022, two MSFIP from the Vascular Access Department
created a video detailing the central line dressing change procedure for Hemodialysis Contracted Service. Subsequently, they provided competency validation on the dressing change on all 11
RNs performing hemodialysis at COH (Table 1).
Improvement in Glo-Germ cleaning validation
In 2021, Glo-Germ cleaning validation was conducted
on all patient rooms. Table 2 (partial record) highlights the
areas requiring improvement for the Environmental Service (EVS) Leaders.
Although Environmental Service (EVS) Leaders consistently monitor staff practices, cleaning validation was selected as one of the IP projects in 2021. MSFIP received minimal guidance, instructions, or demonstrations on performing Glo-Germ cleaning validation before becoming independent to validate cleaning in all patient rooms. Table 2 lists the patient rooms and high-touch areas where cleaning verification was conducted
(Yes = cleaned, No = not cleaned, NA = was not able to perform Glo- Germ). The results were analyzed and shared with EVS leaders, who subsequently worked with their staff to address areas of deficiency.
Improvement of healthcare-associated
infection tracking and analysis
Some technologically savvy MSFIP created additional electronic documents that provided more efficient healthcare-associated infection (HAI) tracking and analysis by IPs. Surveillance of Candida auris, an emerging fungus of concern (Sikora, 2023), is now managed independently by MSFIP. MSFIP were also invited to participate in nursing-related quality improvement projects such as HAI prevention taskforces and data-mining functionality improvements. It is crucial for frontline staff to participate in these projects, as they can provide insights into how proposed changes may impact their workflow before implementation progresses.
All hospital-acquired CAUTI, central line-associated bloodstream infections, and Clostridioides difficile infections at COH require unit nursing leaders or their designees to complete a Case Review Form to the IPD. This process includes reviewing documented care and investigating areas for improvement. One technologically savvy MSFIP converted the Case Review Form into a live document that automatically transfers the information entered into an Excel form. This streamlined process allows IPs to easily compile data, create graphs, analyze trends, and implement quality improvement projects in focused areas. Overall, this innovation has improved workflow and efficiency for IPs.
Paving a career path
In 2022, another concurrent project that contributed to raising awareness of the IP profession was the High School Student Career Path Program. MSFIP independently created an orientation package (Figure 2), managed the scheduling, designed the experience, and created the QR
code for the program evaluation. Following the initial intervention, three out of 21 students expressed interest in pursuing an IP career.
DISCUSSION
MSFIP contributed significantly to maintaining the low SIR in CAUTIs, improving Glo-Germ cleaning validation, and enhancing HAI tracking and analysis. There were no other confounding factors affecting these associations. Additionally, given the exacerbated workload from the COVID-19 pandemic, COH IPs did not have the capacity to conduct these surveillances. Furthermore, quality improvement projects which IPs could only undertake after fulfilling their minimum required duties and responsibilities were the focus of these initiatives.
MSFIP expressed a greater appreciation for IP work and became advocates for the IPD after returning to full duty in their respective units. About one-third of MSFIP expressed interest in becoming IPs. This has significant implications for replacing retiring IPs, estimated to be near 40% (Gilmartin et al., 2021). MSFIP appreciated being able to maintain close to their regular income during their recovery while acquiring new skills and knowledge in infection prevention and enhancing overall patient care quality. Each MSFIP expressed satisfaction in contributing to patient safety and maintaining social connections despite their physical injury and limitations. While this study did not explore benefits to employers, potential advantages may include cost savings from reduced workers’ compensation or disability claims, as well as mitigating costs associated with hiring temporary workers or paying overtime (Government of Canada, Canadian Centre for Occupational Health and Safety, 2023).
Like most quality improvement assessments, this study has limitations. The most apparent is the small sample size, which may limit the generalizability of the results. The constant flow of MSFIP observed in this study may not be replicated at other institutions due to varying policies regarding Modified Work Programs (MWP). Availability of office space and computers could also pose implementation challenges.
Since most MSFIP in this study were RNs, potentially due to their higher injury rates compared to other healthcare workers (based on Occupational Safety and Health Administration, 2013), this may introduce selection bias.
Despite these limitations, COH’s MSFIP program provides significant mutual benefits for injured employees and the employer. Recruiting RNs may necessitate changes in work scheduling and pay structures. In this study, non-RN MSFIP successfully managed daily COVID-19 testing stations for unvaccinated employees as mandated between August 2021 and September 2022. With additional training, they also provided valuable support to the IPD.
However, one-third of MSFIP who expressed interest in becoming IPs discussed their hesitance regarding transitioning for two main reasons. Firstly, they were concerned about potential reductions in pay, as RNs often work three 12-hour shifts with the last four hours being overtime pay, which differs from the pay structure for IPs. Secondly, they expressed concerns about transitioning to working five 8-hour shifts per week, which would result in fewer days off compared to their current schedule. Interestingly, many MSFIP indicated openness to working four 10-hour shifts per week, which they viewed as offering an additional off-day beneficial for work-life balance.
These factors should be carefully considered in efforts to recruit RNs for IPs positions. Future research could explore expanding the MSFIP selection criteria to include more non-clinical staff to potentially broaden the IP candidate pool. Collaboration with the Human Resources Department to explore the financial benefits and cost-savings of such programs could also be beneficial.
Overall, this study underscores the occupational and human resources significance for employers to establish Workers Compensation Programs that provide support for occupationally injured employees undergoing medical treatment and rehabilitation services (Clayton, 2004). Finally, MSFIP fulfilling daily infection prevention and control tasks enabled IPs to focus more on strengthening quality improvement projects that may otherwise not have been feasible.
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