Preventing Infections in Health Care Settings

David Calfee, MD: Infection prevention is often reduced to hand hygiene, with the perception that we are the "hand hygiene police" going around telling people to wash their hands. Hand hygiene is an important part of what we do, but there is much more to it. There has been a great deal of research that has led to evidence-based practices to prevent transmission and infection. Many of these interventions rely on human behavior, things that need to happen correctly over and over again, whether it is hand hygiene, accessing a catheter in a sterile way, or prescribing antibiotics appropriately. At each step, small deviations can increase risk.

Much of infection prevention is really about systems and understanding what gets in the way of doing the right thing, then making that the easiest and most reliable option. It is rarely about an individual failing. More often, there are structural or knowledge gaps that need to be addressed. Infectious disease control is complex, and it really is the responsibility of everyone in health care.

Calfee: A lot of it comes down to how you approach people. It’s less about telling someone they did something wrong and more about trying to understand why something is happening or why it’s a challenge. Too often, we create processes that do not fit into real workflows. Small changes, like bundling supplies for procedures or placing hand sanitizer in more intuitive locations, can make it much easier for people to do the right thing consistently. You really have to observe and work alongside people to understand those barriers.

It is also important to explain the “why” behind infection prevention practices. It cannot just be “do this because we say so.” People want to understand the evidence, the benefits, and even the trade-offs.

Calfee: One major shift over the past decade has been a greater focus on implementation, specifically how we get evidence-based practices to the bedside. There is a well-known estimate that it can take an average of 17 years for a new intervention to be reliably adopted in clinical practice, which is a long time. A big part of the field now is thinking about how we can translate what we know works into real-world care more quickly.

There has also been important progress in reducing high-impact infections. Earlier efforts have focused on targeting device-associated conditions like central line-associated bloodstream infections, catheter-associated urinary tract infections, and surgical site infections. More recently, the field has begun to focus on less-studied areas of prevention. For example, non-ventilator hospital-acquired pneumonia is just as serious as ventilator-associated pneumonia and several times more common, yet it has received far less attention.

Calfee: There are a number of things patients, as well as their family members and visitors, can do to help reduce risk of infection. Hand hygiene is one example we emphasize with health care workers, but it is also important for patients and visitors. For patients with surgical wounds or medical devices, understanding how to care for them properly, especially after leaving the hospital, is also critical.

It is also important that patients understand the reasoning behind certain parts of their care. For example, practices like daily bathing with chlorhexidine in the hospital can reduce the risk of infections, including central line-associated bloodstream infections. Sometimes patients may feel too tired or unwell to participate, which is completely understandable, but helping them understand that these measures are part of their treatment, not just routine tasks, allows them to make more informed decisions.

A lot of this comes back to making sure patients have the information they need. When patients understand why these practices matter, they are better able to participate in their care and help reduce their risk of infection.