You’re usually still a little groggy when your pager goes off. You jolt out of bed, unsure what’s going to come next. Getting awakened for work at 2 a.m. is never fun or easy—but you’re the on-call infection preventionist. Infections don’t know the time of day, and ensuring patient safety is a round-the-clock job.
At large academic medical centers—like UCLA Health, where we work—infection preventionists, or IPs for short, keep patients and healthcare workers from catching and spreading communicable diseases. We come from a variety of backgrounds. Some of us are nurses, some are lab technicians, others have training in public health. We understand how infections spread, and how different infections spread, and how health care workers can keep patients (and themselves) safe when there is no easy cure for a contagious and dangerous illness.
Our role is often hidden. We don’t treat patients, but we touch many aspects of hospital life.
In normal times, our days involve preventing infections patients could get from external devices such as urinary catheters or central lines. We enforce protocols for dealing with viruses like the flu, or stomach bugs. We function as the “hand hygiene police,” constantly reminding our colleagues on the medical units to wash their hands, to wash their hands more, and to remember, later on, to wash their hands again. We inspect patient rooms for hazards, and conduct trainings for staff. We answer questions, and prioritize concerns.
No two days are the same, but the goal never changes: make the healthcare system safer for all. It is the driving force behind the work we do every day—especially now, in the era of COVID-19. This virus has consumed our daily lives at work and at home, focusing our attention on a single, vexing subject.
Before this year, none of us had ever experienced a major pandemic, and while we had prepared for various exotic contagions like SARS or Ebola, we’d never confronted patients with those illnesses. We always realized it might happen one day, and the idea of it was kind of exciting, since we had trained for so long in preparation. But we had no idea how big this outbreak was going to become, and never really anticipated its devastating outcome.
In February 2020, we began receiving many pages, late at night, concerning patients with travel history and respiratory symptoms. Historically, many of these people would have been thought to have the flu, but now there was an added potential diagnosis: Could they have the novel coronavirus? The pages triggered a frenzy of activity. First, a multidisciplinary team, comprised of experts in emergency preparedness, infection prevention, nursing, physicians, hospital leadership, and operations, would hop onto a conference call to determine if the patient met the criteria for COVID-19 testing. Were they displaying symptoms of respiratory disease due to unknown cause, such as cough, fever, difficulty breathing, and shortness of breath? Had they traveled to an area with known transmission—at that time, China, Iran, Italy, South Korea, or Japan?
More and more patients qualified for testing as we reached the middle of March. And as soon as we deemed someone a person under investigation for COVID-19, the on-call team would head into the hospital. For IPs, this meant consulting a fat binder, prepared by the emerging infectious diseases team, that contained all the official COVID precautions and protocols: what protective clothing to wear, what disinfectants to use, and so on.
We conducted on-the-spot trainings to prepare the staff on the most recent guidance, collecting personal protective equipment (PPE)—N95 masks, gowns, gloves, and face shields—and showing doctors, nurses, and respiratory therapists how to take these items on and off, step by meticulous step. If a nurse was going to take a nasopharyngeal specimen, we advised them to double bag the sample and wipe the outer bag with a bleach wipe. As we helped a doctor put on the appropriate PPE, we reminded them of crucial precautions such as sanitizing their gloves before removing them.
As the care team got to work, we stood watch outside patient rooms, peeking through interior windows, ready to answer questions or provide tips. No one really understood much about COVID then, so IPs had to exercise extreme caution. We did not know how COVID spread, so the PPE we gave health workers was extensive (including extended-cuff, doubled gloves) and completely disposable (today we wear reusable gowns that we wash between uses). We instructed nurses to wipe outer biohazard bags with bleach (now that we know this refuse isn’t dangerous, we follow standard disposal processes). When staff rolled a patient in a gurney down a hallway, environmental services workers followed alongside with a Swiffer-style mop, decontaminating the path the bed traveled over the floor.
Treatment teams started utilizing cell phones or white boards to speak to one another, flashing written messages instead of entering and leaving a patient’s room and wasting precious, disposable PPE. Stationed outside of a room in one of these moments, we were dying to know what a nurse was scribbling on her white board. Often the message was something like, “Do I wipe the specimen bag with a bleach wipe or alcohol wipe?” We’d write, “Bleach wipe.” The nurse would give a thumbs up, and continue with her work.
To minimize risk and PPE use, we did a lot to try to prevent people from walking in and out of patient rooms if they didn’t absolutely have to. Visitors, of course, were not allowed at all, but we tried to keep staff away as well when it was feasible. This meant teaching doctors, nurses, and others new ways to do their work. IPs coordinated with hospital supply workers to make sure rooms remained stocked with ample supplies: receptables for removing PPE, wipes for cleaning surfaces, gloves for patient care, hand sanitizer, biohazard bags for specimens. Usually such items would have been kept in a central supply room, with care workers going in and out to grab what they needed whenever they needed it.
We worked with the facilities team to minimize potential maintenance issues and repairs. We made sure they aggressively monitored sinks, doors, patient care equipment, and ventilation systems. Normally, nutrition staff delivered meals directly to patients. Early on in our pandemic response, we instructed them to hand trays of food to nurses, who would then take the meal into the room. We also worked to remind nurses to help disinfect highly used surfaces when they were in a patient room, since the environmental services team couldn’t enter until discharge.
Anyone who did need to enter a potential COVID-19 patient’s room had to add their name to the Patient Room Log, which listed employee ID numbers, names, times in/out of the room, any safety concerns, and their preferred contact information. If this patient’s test results came back positive, every person who had been in the room would be monitored for 14 days.
In March and April, as we realized that COVID-19 was not going away, we expanded our education efforts to the entire hospital, creating new policies, conducting large trainings on PPE guidance, and walking through units to answer any questions that staff may have had.
We hit a stride that never really slowed. Every day, you would come to work with a blank slate approach. Things changed so often that guidelines provided one day might be radically modified the next, based on new information. Every month, you would think things were going to get better—but they never did.
The worst-case scenario we had planned for in April finally hit us over the holidays—cases in the Los Angeles area exploded. We went back to our binders to remember all of the systemwide protocols that the hospital had laid out—adjustments like setting up intensive care units in surgical areas, housing adults on pediatric floors, and “cohorting” more than one COVID patient in a room.
Inside and outside the healthcare setting, COVID-19 became all anyone talked about. We are all fortunate to have received the first dose of the vaccine. There is light at the end of the tunnel.
This work is exhausting, but we’re thrilled to be doing it. It’s what we trained for, and it’s helping keep people safe.
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