Phenelle Segal, RN, CIC, FAPIC, founder of Infection Control Consulting Services (ICCS), answers 10 questions concerning the future of infection prevention in the COVID-19 era.
Q: What trends are you seeing across the non-acute sites that you work with when it comes to infection prevention during COVID-19?
Phenelle Segal: Across the board, non-acute-care sites, including outpatient settings, that were unfamiliar with pandemic preparedness, particularly droplet precautions and the level of personal protective equipment (PPE) required for a virus like COVID-19, have risen to the occasion and shown incredible diligence and expedience in turning their sites into "COVID-safer" sites. The trend for being "COVID-safe" is continuing, and I'm not seeing any pull back to "previous times," which is encouraging. COVID-19 is here to stay for an extended period, and the non-acute sites need to maintain this level of diligence moving forward.
It's worth noting that in August, the governor of New Jersey enacted an executive order encompassing all long-term care settings in response to the severity of outbreaks that occurred in the New York tri-state area (New York, New Jersey, and Connecticut) at the beginning of the pandemic. To fulfill the requirements outlined in this order has required extensive work and communication strategies. These requirements and mandates have resulted in solidifying policies and procedures. However, regardless of state mandates, the pandemic has led to a major emphasis placed on processes, particularly in long-term care, and greater oversight is now in effect.
Overall, I'm seeing a healthcare community outside of acute care that has always had a strong commitment to infection prevention and adhering to a robust program truly rising to the forefront of the COVID-19 health crisis.
Q: How has infection prevention since COVID-19 changed? What do you see happening in the future?
PS: Adherence to the status quo and repeating the same processes over and over, depending on the facility, has definitely changed and is evolving. Existing protocols have tightened up and new protocols have been introduced. Staffing has been challenging and needed to be adjusted for a few reasons. When we were shut down, many non-acute sites had to furlough staff, with some choosing to leave the healthcare arena to find alternate work. As a result, many didn't return to their previous jobs when we started opening up. That resulted in a shortage of skilled workers.
In addition, many staff members have school-age children. For staff with such children doing remote learning, they needed to change their work strategies to accommodate staying home with their children.
Last but not least, COVID-19 fatigue has resulted in many healthcare workers leaving their jobs and finding other, less stressful professional avenues. Going forward, education will remain a huge necessity, especially teaching practices unfamiliar to healthcare workers, such as donning and doffing of PPE that was primarily performed in the acute-care setting. Non-acute-care settings have needed to figure out how to train and educate staff and then establish compliance monitoring and strategies for reporting with feedback as well.
Q: What should facilities be doing now to prepare for what's next?
PS: Continue to enforce and maintain protocols and practices that were developed and be mindful of letting one's guard down, particularly in the areas of the country that have experienced a low or steady downward trend of coronavirus cases. I'd also encourage facilities to consider increasing PPE and disinfectant supply resources as the winter months are upon us and we are seeing an exponential increase in cases before the true winter months get here. This is of great concern. Maintaining diligence, communication, and auditing of processes remains paramount in fighting this pandemic.
Q: Following up on the previous questions, what do you see as the biggest challenges to preparing properly?
PS: Several challenges continue across the continuum of care: Restricted supplies, particularly N95 masks, counterfeit KN95s, shortage of disinfectant wipes; budget constraints as a result of several unforeseen costs; overall staffing issues and COVID-19 healthcare worker burnout (as discussed earlier), particularly caused by high levels of professional and personal stress, along with the wearing of PPE, depending on the facility setting and services provided. Maintaining effective communication can be a challenge but is absolutely essential. Managers need to maintain an open-door approach and share information from external sources, such as state orders and CDC guideline changes, and internal information.
Q: How should facilities approach new regulations resulting from COVID-19, and what do you see as the potential long-term impacts?
PS: The biggest challenge with new regulations, particularly at the individual state level, is the difficulty in interpreting the language as written in the new orders and requirements. Many would argue that regulations are mostly subjective and open to interpretation. This has resulted in much confusion and anxiety thus far, especially for administrators and management teams as they are struggling to comply with the law and put new practices into place. That being said, I expect it to get easier as time moves on and we become more used to the "new normal."
Q: How does all of this compare to past pandemics?
PS: There is no comparison that I can accurately discuss, but what I can do is mention that this is most likely the pandemic of all pandemics, akin to an earthquake when we talk about the big one. Lessons learned from this will certainly carry over to future pandemics, but ones that we can only hope are not as devastating as this one. I don't believe this will be our last major respiratory pandemic, but we certainly will be better prepared for the next crisis.
Q: Ambulatory surgery centers (ASCs) are now required to have an infection preventionist on staff. What should administrators, owners, and human resources leaders consider when they start their search for this new staff member or are they better off certifying someone from within?
PS: Hiring from the outside or training someone from within is very much dependent on several factors, including the type of facility and services offered by the surgery center as well as the infection prevention designee's skills, interest in taking on this role, time allocation, and other factors. It also depends on the current state of the infection prevention program. What is the "right approach" for ASCs will be very much individualized. Many surgery centers appoint an infection prevention designee and hire an external consultant to onboard and assist the designee with developing and implementing a new program or maintaining an already established program.
Q: Can you please clarify the guidance around an infection preventionist on staff for a long-term care/skilled nursing facility?
PS: Between the end of 2016 and 2019, long-term care facilities were mandated to include several infection prevention components for participation. This culminated in designating staff members to the role of infection prevention that included specialized training. With COVID-19 attacking the elderly in facilities since March, individual states have recently enacted executive orders, for example the aforementioned New Jersey order and an order from California in late September. These requirements, depending on the state, can be very stringent.
Q: As home health providers need to treat patients in home, what are recommended practices for home health staff to protect themselves while keeping patients safe?
PS: Follow CDC guidance and the basic principles of prevention of acquisition and/or transmission of COVID-19. In addition, the National Association for Home Care and Hospice has an extensive resources page that I would encourage everyone that is involved in home health to review. The page includes FAQs, information for patients and caregivers, and much more.
Q: Can you share any insights on updated point-of-care (POC) testing protocols for providers?
PS: POC technology is changing frequently. Companies are turning out products that are easier to administer, turnaround faster, and produce fewer false negative results. However, testing is not foolproof. Besides facilities enacting their own rules and policies around testing, what facilities need to do will also be dependent on state regulations. POC testing is mandated in several states for long-term care settings due to the outbreak risks in those settings. I believe that will continue into next year as we expect cases to rise again with winter around the corner. It is important to understand that POC testing has limitations; consider exactly what your goals are for doing POC testing and how you will use these results.