Relearning Forgotten Lessons About Infection Prevention

By Saskia Popescu, PhD

I knew early on that the COVID-19 pandemic would hit the United States hard. In healthcare, it’s no longer a matter of if but rather when and for how long. Thanks to globalization, every city in America is twenty-four hours away from any outbreak in the world. My role as a senior infection prevention epidemiologist has taught me that there are warning signs before cases even reach our hospital, let alone American soil. The mask shortages that began well before cases were climbing in the United States, was one such canary in the coal mine.

These lessons were burned into the brains of infection preventionists in 2014 when Ebola was spreading across west Africa and the Dallas Ebola cluster changed the face of U.S. healthcare and biodefense forever. I still remember the daily scramble to update personal protective equipment (PPE) educational tools and get enough materials to train my frontline staff. Those were 16-hour days followed by multiple pages and calls throughout the night. And did I mention that I had a wedding scheduled in the midst of it all? Fitting for an infectious disease nerd though, right?

COVID-19 though has been a different kind of challenge. We have forgotten the lessons we should have learned in 2014. Preventing the  disruptions that emerging infectious diseases cause to healthcare were no longer prioritized by most hospital administrators. The tiered hospital system set in place by the Federal government to prepare for and respond to special pathogens is now drastically reduced due to a lapse in funding that was not renewed. While that system was not perfect, it ensured that there were dozens of treatment and assessment hospitals that had invested in enhanced readiness for handling patients infected with special pathogens like Ebola. The funding for all but ten of the regional treatment centers expired in the middle of COVID-19 hitting the United States. Sadly, this almost went unnoticed as the United States became inundated with COVID-19 cases.

Ironically, just six months before COVID-19 hit the United States, I defended my doctoral dissertation on the roadblocks for investing in infection prevention across U.S. hospitals and the implications for biopreparedness and biodefense. It’s almost breathtaking to see how this pandemic has exposed all of the gaps and weaknesses in our healthcare system that I highlighted in my dissertation. We have been reliant on private hospitals to invest in costly prevention strategies for an event they do not deem a priority. The consequences of that mismatch between the economic incentives of the healthcare industry and the reality of how disruptive an outbreak of a highly transmissible disease can be has demonstrated that the old model is broken and desperately in need of changes. Being prepared for an outbreak, let alone a pandemic, is not just about stockpiling enough ventilators or masks. More importantly, do the leaders of healthcare organizations value their investment in preparedness for such outbreaks? Sadly, there is a lot of variability across hospitals in the United States.

I’m fortunate that my hospital system, which includes six facilities and over 100 outpatient clinics, started investing in high-consequence disease preparedness in late 2018. While none of our hospitals were designated treatment or assessment hospitals, we recognized that frontline hospitals played a unique role in biopreparedness and that outbreaks of novel or unusual diseases could be massively disruptive. Thankfully, this meant that we were paying close attention to the COVID-19 outbreak in January when the first case occurred in the United States. We immediately began holding meetings of key stakeholders in the system, reviewing our stockpiles of PPE, and updating our supply chain management in order to evaluate our readiness.

While no hospital was fully prepared for COVID-19, I don’t think anyone could have anticipated the headaches caused by PPE shortages and testing failures. In late February and early March, it was a mess of trying to establish the processes for extended use and re-use of N95 respirator masks, which entirely went against the grain for what we’ve done my entire career in infection prevention. Doctors, nurses, techs and everyone else on staff were deeply frustrated. We became distrustful of the wavering CDC guidance on airborne isolation precautions and when N95 masks were needed or not needed. Was the change in guidance due to new data about the virus or concerns about supply chains?? Despite educating the medical staff that coronaviruses in general are droplet spread, with the risk of aerosolization increased during certain procedures, they were scared and wanted to wear more PPE. I’ve had healthcare workers want to wear Tyvek suits like they were working in a biocontainment lab and douse everything with bleach. But given the scenes of lockdown in China, the breakdown of healthcare in parts of Italy, and the constantly changing guidance issued without adequate explanation or justification, who can blame them?

From trying to acquire as much PPE as possible to having to establish UV disinfection processes to enable use to re-use what PPE we did have, this has been a challenging time. Never did I think we would be running on a few days supply of masks and disinfecting wipes, or have to rely on local breweries to make alcohol-based hand sanitizer. The information overload and sensationalism during this pandemic has been not only exhaustive, but deeply frustrating for those working in public health and healthcare. I never expected that I would have to counter misinformation from the White House about the therapeutic value of injecting or drinking disinfectants. The amount of time we’re having to spend to combat poor information is time that we are not doing PPE training or supporting staff in other ways. Even the information on the CDC site can be confusing or misleading: N95 masks are touted as the preferred means of protection but there is also guidance that these types of masks should only be used for certain procedures. These subtle nuances are ones that become much larger problems when healthcare workers are scared.

These are just a few of the hurdles I’ve seen and frankly, the list is quite substantial. With that being said, the amount of overwhelming support I have received, both from hospital leadership and the community in general, and sheer force of will I’ve witnessed among my colleagues has been inspiring. I’ve seen nurses purchase baby monitors to ensure their COVID-19 patients on extracorporeal membrane oxygenation (ECMO) could be monitored continuously while keeping the door closed to maintain negative pressure. I’ve had physicians offer to consult on patients through a single hospitalist, meaning that they won’t be paid for their time consulting, in order to ensure the patient gets the care they need while reducing the number of people going into the room and the amount of PPE used up. I’ve gotten to work with a remarkable group of infection preventionists who have had to problem solve in situations we’ve never even imagined. Frankly, it’s been amazing to see their utter dedication to infection control and keeping our patients and staff safe. .

The COVID-19 pandemic has demonstrated that we can no longer ask if we should invest in public health and healthcare biopreparedness. Outbreaks will happen, but we can choose how ready we want to be. For those of us on the frontlines, I think we can safely say that lackluster investments in these readiness tools needs to be a habit of the past. The important questions now are how do we invest in a smart, sustainable way that will prevent a catastrophe like COVID-19 from occurring in the future?

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