Infection control lessons that we have learned so far [PODCAST]

 

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“We are in the midst of the COVID-19 pandemic, but it’s already very clear that the infection prevention community in the U.S. has never faced such an enormous challenge. We have learned many things that will make us better prepared for the long term.

We are far too reliant on single-use disposable products. Having a large supply of cloth surgical gowns and isolation gowns that can be laundered is essential. I’ll comment on disposable face masks below. Less reliance on disposables will also be better for the environment.”

Michael Edmond is an infectious disease physician who blogs at Controversies in Hospital Infection Prevention.

He shares his story and discusses his KevinMD article, “Infection preventionists are true heroes, and other things we’ve learned so far.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Michael Edmond. He’s an infectious disease physician. He’s an infection control specialist. He blogs at the site Controversies in Hospital Infection Prevention. He wrote the KevinMD articles “Infection preventionists are true heroes, and other things we’ve learned so far” and “How to avoid COVID-19 infection at work: tips from an infectious disease physician.” Michael, welcome to the show.

Michael Edmond: Thank you. Happy to be here.

Kevin Pho: So we’ll get into all of that in a bit, but first off, tell me your story and your journey to where you are today.

Michael Edmond: Sure. So I’m trained as an internist. I did a fellowship in infectious diseases, and my whole focus throughout my career has been in hospital epidemiology. I broadened that out more recently, in the last five years or so, to do quality and safety, and most recently got an MBA.

Kevin Pho: We are filming this on the Fourth of July weekend, and COVID-19 is ramping up in many parts of the country, particularly the South and the West. Now, I was wondering if you could share some of the infection prevention lessons that we’ve learned over the past four to five months.

Michael Edmond: Sure. Yeah, I think we’ve learned a lot of lessons. One of the pieces that I wrote that you published was about my thinking about two weeks into the outbreak and all the things that sort of became revealed that were pretty scary. I think one of them was I realized how much we rely, particularly in infection control, on single-use items, things like isolation gowns and face masks and all these types of things that all of a sudden became in short supply, and we were very scared that we weren’t going to make it through the outbreak with enough of these supplies.

And then you step back a bit, and you see the reason for that is that these supply chains were all really geographically concentrated in China, which is where the outbreak started. And so the factories went down, and we weren’t able to get the supplies that we needed. You couple that with what hospitals tend to want to do, which is just-in-time inventory management. You want to keep huge supplies of inventory, and so you keep what you need. But then in a time like this, in an outbreak where you’re going to have a huge demand all of a sudden, a big spike, you may not have enough of everything that you need. So those were some of the initial things that we thought about.

And then we also thought about the standards that we use. When we think about using anything in medicine, we always compare it to what we think is the best. So if there’s a new model of a face mask or an N95 mask or anything, it’s compared to what we already have. And then what we found was that because we didn’t even have what we needed, there were recommendations for health care workers to do what they could do, if that meant wearing a bandana to work.

And that was just really, even though I had done infection control for 25 years, that was beyond my wildest dreams, that we would ever end up in a situation where we would say something like, “If you want to wear a bandana, you can.” We were fortunate at Iowa in that we never ran out, even though we were scared that that could happen. But those experiences for me were just incredibly eye-opening. I never dreamed that I would find myself in that situation.

Kevin Pho: I think what we found was a lot of hospitals were stretching single-use items for multiple uses, days at a time, weeks. How hard is it for them to pivot away from that model?

Michael Edmond: Well, I don’t think that’s happening yet, because we’re not through the pandemic at this point. So I think you’re still seeing in most hospitals a lot of reuse of items that are designed for single use. So we wear our face masks longer than we normally would. Pre-COVID, it was one patient, one encounter, you throw it away. Now we’ll tend to leave that mask on as long as it’s not wet or soiled. So we haven’t yet pivoted away from that.

When we’ll do that, I suspect it’s probably another year or so, when the outbreak finally dies down, when the supply chains stabilize. Now, what we are seeing with some items is that some companies are opening new factories in the United States to augment the supply, so that we’re going to be able to get these things more easily. But all of that takes time, and those factories aren’t up yet, so we’re still pretty much in the same mode that we’ve been in for the last three or four months.

Kevin Pho: Now, what are some other infection prevention issues that hospitals are facing going forward?

Michael Edmond: Well, there are many. So there’s a lot of issues around testing: who to test, when to test. One of the problems with testing has been, just like with all the PPE items, the testing reagents are also in short supply, so we can’t test as many patients as we would like to test. So there are those issues.

There are the issues around health care workers who are exposed, and they may be exposed at work, or, more commonly in our setting, they’re exposed actually at home, off, when they’re not at work. What do you do with those health care workers? How many of those health care workers can we quarantine before we start to impact the level of care that we’re able to provide to patients in the hospital? And then how do you keep a hospital running, doing the things that a hospital normally does, and then add COVID on top of that?

And I think what COVID has done is it has exposed a lot of the weaknesses in our health care system. I mean, we knew they were there, but now we’re really living them on a daily basis, where we have a system that really isn’t designed at all to do its normal work and a pandemic on top of it.

Kevin Pho: Are hospitals prepared going forward? We are six months into the pandemic, and now it’s flaring up again. Some say this is just a continuation of the first wave. How are hospitals equipped going forward?

Michael Edmond: Well, I think that for most hospitals, they really haven’t had a chance to take a breath yet and sit back and do long-term planning. Now, there are some areas of the country where it has become relatively quiet, and so they’re probably able to do a little bit more. But I would say for us, we’ve had a pretty steady number of patients and a pretty steady pace of issues that are coming at us, so that we haven’t really begun to look at long term what we’re going to do. We’re still fairly focused on what’s happening today and what planning we need to do for the next couple of weeks.

We certainly do a lot of work on, and have done a lot of work on, projections of how much PPE we need for a longer period of time. But the real work of doing really good long-range planning, we’re not there yet, unfortunately. We’re still a lot of times working day to day.

Kevin Pho: I was just reading the newspaper earlier this morning. We’re having record numbers every day in the United States. What needs to be done to turn that around?

Michael Edmond: So I think that one thing that has to happen is that we really have to move PPE use into the community, and not sort of, “We’d like you to, and we hope that you do it.” I think it just has to become a standard that every time a person leaves their home, they leave with their face covered, and unless you’re in a room by yourself, you’re going to have your face covered. And that’s tough to do in the U.S., but I think until we do that, we’re not going to get control of the outbreak.

And it’s difficult, and I realize it’s difficult, particularly for young people, to really focus on social distancing, which we have to do. But knowing that that may not be perfect, that’s all the more reason why we need to have PPE for people in the community. So I think for me, if there’s one thing that we could do, that would be it. Get everybody in a face mask or a face shield every time they’re out of their house.

Kevin Pho: And what’s your opinion about schools in the fall? I’ve heard a lot of pros and cons, but from a public health, infectious disease standpoint, what’s your opinion?

Michael Edmond: Well, I think that at least at the university level, it looks like most universities plan to open, and I think even at the lower levels, high school, grade school, it looks like most of those will open as well. I suspect that there will be a lot of cases of illness, and my prediction is the schools probably won’t be open all that long before they’re closed again.

And the good thing is that young people tend not to get very sick with this infection, but the issue, of course, is that they bring it home to their parents and the grandparents, to people that may have immunocompromising conditions, who may not do well if they get this infection. So I think, try as we might to have a normal school year this coming year, I kind of doubt that that’s going to play out well. I suspect the schools will close.

Kevin Pho: Now, what’s something that you know now that you wish you knew back before the pandemic started?

Michael Edmond: Well, one thing for me, just in my job, in my little world, would be to pay more attention to PPE inventories. Now, if you just looked at the numbers, we had, I don’t know, three, four million face masks, and that sounds like a massive amount. But when you realize how you can burn through this kind of material when you’re seeing lots of patients, and not knowing if you’re going to get any more, which was the case when we started, you realize that you could burn through all your PPE, and then what are you going to do? So that would be one.

I think another thing for me is to really think about things more openly. I never thought this would happen. I have done infectious diseases and infection control for 25 years, and I sort of thought, “Medicine is advanced. The U.S. is very advanced. I can’t envision that we’d be in a situation where we couldn’t manage it, or that we’d be in a situation where we didn’t have the basic supplies that we needed to do our everyday work.” None of that really was in my reality.

And so it’s been kind of humbling for me, because I realized that I was really not on the mark with that, that these things can happen to us. And I suppose, for those of us, the last pandemic was a hundred years ago, so there are not very many people around who experienced that. And so I think you tend to think that what you’ve experienced is what it’s always going to be. I think that was a big lesson for me.

Kevin Pho: We’re talking to Michael Edmond. He’s an infectious disease physician and infection control specialist. He blogs at the site Controversies in Hospital Infection Prevention. Michael, what is your take-home message for the KevinMD audience?

Michael Edmond: So I think if I have one piece of advice for people, it’s sort of what we’ve already talked about, which is: Don’t leave your house unless your face is covered. Do your job to prevent infection. And I’m sure I’m preaching to the choir, knowing the type of people who are your followers, but I think for the public at large, what we can do in the medical community to teach people, to role model, to encourage them to use PPE appropriately in the community, is really important.

Kevin Pho: And how could people get a hold of you?

Michael Edmond: They can email me at [email removed by the editor], and they can also go to my blog, and there’s a contact email for me there as well.

Kevin Pho: Fantastic. Thank you so much for your insight, and thank you so much for your time and being on the show.

Michael Edmond: Thank you, Kevin.

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