Infection prevention staffing needs can vary widely by facilities, but in the absence of an analysis of the actual duties and labor required, many hospitals still rely on outdated IP-patient bed ratios. The result is that the old stereotype of IPs crunching data in isolated silos still exists, although ongoing research is showing more resources are needed for important patient and staff interventions.
In the initial phase of a continuing study, researchers documented care delivery and IP tasks in exhaustive detail, showing that only such a comprehensive quantitative assessment can show the staffing level needed.
In the process, they showed that current staffing ratios — for example, .5 IP FTE per 100 beds or 1 IP per 100 beds — underestimate the work required. Though it is not a ratio that can be applied to all facilities in the absence of analysis, the researchers found that 1 IP per 69 beds was an accurate reflection of the job in their system. Thus, the benchmarks leave infection control programs understaffed by 31% to 66%. The more accurate 1:69 bed ratio considers duty demands of affiliated ambulatory care, long-term care, and home care.
The bottom line is that the benchmarks cited in staffing studies from 2001 to 2017 are invalid, says lead author Rebecca Bartles, MPH, CIC, FAPIC, an IP at Providence St. Joseph Health System in Renton, WA.
“One of the whole points of the paper was not to use those benchmarks, but to really try to understand whether those benchmarks are valid,” she tells Hospital Infection Control & Prevention. “When we did our quantitative approach, we calculated the actual labor needed that an infection prevention program had to do. After that was complete, we went back and said, ‘What would this look like if we were to compare it to the existing benchmarks?’ That is how we came up with 1 IP per 69 beds.”
The complex analysis was performed at a large healthcare system in five states. Bartles and colleagues generated “department-level detail for 34 hospitals, 583 ambulatory sites, and 26 in-home and long-term care programs.”
According to the authors, “Required IP activities for each physical location were also tallied by task. Type of activity, frequency (times per year), hours per activity, and total number of locations in which each activity should occur were determined. From this, the number of hours per week of infection prevention labor resources needed was calculated.”
Bartles highlighted some of the findings in the following interview with HIC.
HIC: Just to clarify, you showed a 1 IP per 69 beds ratio was appropriate for the facilities study, but you are not arguing that should be the new benchmark for other hospitals?
Bartles: The conclusion we came to — the biggest takeaway from the exercise — was that you can’t use a number like that to base your staffing on. It is not a one-size-fits-all type of thing. You really have to do a quantitative assessment of the needs of your organization. Although a lot of the press the article has gotten has been around that 1 IP per 69 beds, I am not necessarily advocating that model. That’s just what our organization found our ratio would be.
HIC: With the methodology demanded by this study, the conclusion was that the older staffing ratios are invalid. But you are continuing and expanding this study and may ultimately come up with a ratio that is more broadly representative across facilities.
Bartles: The surveys and the benchmarks in the literature tell us what everybody else has always done. It doesn’t give us what we actually need. That is the big takeaway. If an organization really doesn’t understand their infection control needs, they have to do some analysis.
We have a group of corporate infection prevention directors that meet once a month, and they are representative of some of the bigger systems in the U.S. A number of other systems are using this model, and we will hopefully combine and publish the data we gather during the follow-up study. Potentially, then, we could provide a benchmark that might be more representative of the ideal state.
HIC: In the interim, are most infection control programs inadequately staffed?
Bartles: In my experience at least, the majority of hospitals are understaffed. The only benchmark out there prior to this article was like one IP per 100 beds or .5 IP per 100 beds. That’s really how everybody is staffed, and it isn’t sufficient.
HIC: Does that mean that HAIs are occurring that could otherwise be prevented?
Bartles: I think it’s hard to be able to draw a positive relationship between an increase in IP staffing and a decrease in HAIs.
There is definitely a return on investment to be had by increasing the robustness of an infection prevention program, but it is hard to quantify what that might look like in numbers of infections prevented.
HIC: In this relatively new century we have seen outbreaks ranging from SARS to Ebola and a new emphasis on value-based purchasing that requires HAI documentation and reporting. Has the job of IP become complex and labor-intensive?
Bartles: If you look at infection prevention over the last 40 years, the job has become immensely more complex. The addition of state and federal mandated surveillance has taken a lot of our time and attention from patient care areas and put us behind a computer. I don’t think that has been a positive change. We can’t simply redirect our attention toward surveillance. We have to add additional resources to ensure that we are still able to do the educational and consultative things so that we still have a presence in the patient care area.
HIC: You found that IPs in your study were spending the majority of time on surveillance and had less time to conduct rounding in patient floors.
Bartles: Yes, we did time studies with every IP in the organization. Surveys and rounding are location-specific activities, but the rest of what we do is not.
We wanted to make sure that we captured things that had to physically occur at a location in a unit or patient care area and then those things that were done behind a desk or on the phone in an office. We surveyed the IPs and found they were spending most of their time on surveillance and very little of their time on education and rounding. We have received a lot of feedback since the paper was published. This is very representative of IP programs across the U.S.
HIC: Some facilities in your study were able to enlist auxiliary workers to enter surveillance data so the IPs could continue making rounds. Why is that activity so important?
Bartles: We talk about two types of rounding, one being sort of daily rounds — just being present in the patient care area, boots on the ground, and eyes on what’s happening. We are educating folks about hand hygiene and isolation and answering questions. Being part of the care process is one very important piece of rounding.
The other type of rounding is the environment of care, conducting very detailed routine environmental surveys to ensure that the areas where we are seeing our patents are safe.
So, the former is more focused on the caregivers themselves, and the latter is focused on the care environment. Obviously, we can’t do any of that if we are sitting behind a desk doing surveillance for 40 hours a week. The recommendations that we made internally resulted in some adjustments in staffing.
- Bartles R, Dickson A, Babade O. A systematic approach to quantifying infection prevention staffing and coverage needs. Am J Infect Control 2018;46(5):487–491.
