The concept of the learning hospital is distinguished by ceaseless evolution of erudition, enhancement, and implementation. A learning hospital, where “science, informatics, incentives and culture are aligned for continuous improvement and innovation (p 16),” need not be supported by additional funding from the healthcare system. ¹ Instead, it is a culture within the system that seeks evidence-based and value-driven results through facilitating an environment in which nonfaculty learners at all levels are engaged in research and the pursuit of scientific advancement. In the learning hospital setting, knowledge is collaboratively gained and shared, leading to improved patient care, higher quality, and lower costs.Reference Liu, Morehouse, Baker, Greene, Kipnis and Escobar ² Knowledge based on local data can support practice changes and enhanced implementation. However, no models of the learning hospital as applied to healthcare infection prevention have been published.

We reviewed the entirety of our published manuscripts from January 2004 to June 2019 under the framework of the learning hospital. These references were reviewed by authors O.H., K.A., and M.S. Publications authored by members of the Virginia Commonwealth University (VCU) Healthcare Infection Prevention Program (HIPP) were excluded if they were coauthored with practitioners from outside hospitals or the research setting was outside the VCU Health System (VCUHS). All publications related to any component of our infection prevention program were included in this review. Although the bulk of our published work is in infection prevention, we included infectious diseases clinical publications that were cowritten by learners consistent with the concept of the learning hospital. These published manuscripts were divided into areas of focus based on the infection control topic or intervention: hand hygiene, universal gloving, contact precautions, healthcare worker apparel, personal protective equipment, bare below the elbows, antimicrobial stewardship, chlorhexidine bathing, environmental disinfection, methicillin-resistant Staphylococcus aureus (MRSA) and other multidrug-resistant organisms, surgical site infections, perspectives on hospital-acquired infections and patient safety, diagnostic test stewardship, gastrointestinal infections/C. difficile, S. aureus, patient decolonization, compliance with process of care measures, oncology care, implications for infection control best practice, and editorials. We summarized the publications by describing how each manuscript is relevant to the mission of the infection prevention program. We report the involvement of nonfaculty learners (eg, students, interns, residents, fellows and infection preventionists [IPs]) in the varied research projects, and we tallied the number of publications that were funded by grants. The attending physicians of the VCU HIPP over the past 16 years are termed faculty learners in this summary.

The Healthcare Infection Prevention Program at VCUHS, an urban, 865-bed hospital, performs hospital-wide surveillance according to the Centers for Disease Control and Prevention’s National Healthcare Safety Network methodology. A medical director, who is both the chair of the division and a hospital epidemiologist, and a nursing director lead the HIPP. The leadership team also includes 3 associate hospital epidemiologists, 1 of whom leads our antimicrobial stewardship program, which is administered within the HIPP. In addition to HIPP leadership, 10 trained and certified IPs develop policies and procedures to minimize hospital-acquired infections (HAIs) and offer hospital disinfection recommendations. The HIPP also includes a nurse clinician who oversees the unique pathogen unit, a medical technologist, an executive secretary, a program support assistant, a data analyst, an information technologist, and a full-time project coordinator for the hand hygiene monitoring program. Important HIPP changes over the last 16 years have included the addition of the aforementioned hospital-supported data analyst who assists with research coordination (added in 2013) and a dedicated third-year infectious diseases fellowship (1 fellow per annum) in infection prevention (added in 2014).

The HIPP prioritizes weekly staff meetings, monthly Infection Control Committee (ICC) and monthly Champions of Healthcare Infection Prevention (CHIPs) meetings. The ICC consists of all members of the HIPP department; pharmacists; microbiologists; and regulatory, nursing, physician, operating room (OR), and central sterile staff members. The CHIPs include nurses from each inpatient hospital unit. During CHIP meetings, IPs share infection prevention knowledge and practice changes with the CHIPs. The CHIPs then share this information with the nurses and other employees of their respective units. Through a strong core HIPP team, nonfaculty learners, and monthly collaborative meetings, infection prevention practices are enhanced and knowledge is gained and shared.

The HIPP team actively partners with and mentors a diversity of nonfaculty learners in the healthcare system. Nonfaculty learners include college and medical students, interns, residents (both medical and pharmacy), fellows, IPs, non-IP nurses, and non-IP HIPP staff. Nonfaculty learners actively seek research experience within the HIPP, and their involvement in the program is encouraged. Since 2003, 87 nonfaculty learners have contributed to HIPP research and manuscript publication. Nonfaculty learners actively participate in multiple HIPP functions, including attending meetings, project design, and data collection and analysis, all to serve the quality and safety mission of the institution. Herein, we describe a learning hospital model in which collaboration among staff and nonfaculty learners results in the critical exploration and assessment of a horizontal infection prevention program.

Members of the HIPP published 121 manuscripts consistent with the theme of the learning hospital: 92 original investigations, 21 perspectives and editorials, and 8 case reports (Table 1). HIPP members also published 12 clinical infectious diseases manuscripts on H1N1 influenza, fungal infections, HIV/AIDS, bacteremia/septic shock, and uncommon infectious diseases under the learning hospital framework.Reference Wenzel and Edmond ^{3 –} Reference Derber, Elam and Bearman ¹⁴ Only 4 of 121 (3%) of the publications were funded by grants. Of all the manuscripts published, 85 of 121 (70%) involved either a student, intern, resident, fellow, infection preventionist, non-IP HIPP staff, or non-IP nurses. The learners included 9 college students involved with 8 manuscripts, 16 medical students involved with 18 manuscripts, 4 graduate students involved with 13 manuscripts, 11 interns or residents involved with 13 manuscripts, 19 ID fellows involved with 36 manuscripts, and 6 infection preventionists involved with 15 manuscripts. A total of 62 nonfaculty learners (ie, students, interns, residents, fellows, IPs, non-IP HIPP staff, and non-IP nurses) were either first or second authors, representing 77 of 121 (64%) of all manuscripts published by members of the HIPP. Since 2016, the number of nonfaculty learners as first and/or second authors of published manuscripts has continued to increase (Fig. 1 and Table 2). As of June 2019, the HIPP has had a total of 17 publications, all with nonfaculty learners as first and/or second authors (Fig. 1 and Table 2). Notably, the first and second authors of this manuscript (O.H. and M.S) are college students. Furthermore, we sought to analyze the trend of nonfaculty physicians (ie, medical students, residents, and fellows) as first or second authors over the past 16 years (Fig. 2).

Table 1.

Summary of Learning Hospital Infection Prevention Projects

Note. ADE, antibiotic de-escalation; ARV, antiretroviral; AS, antimicrobial stewardship; AUD, alcohol use disorder; BBE, bare below the elbows; BSI, bloodstream infection; CDI, Clostridioides difficile infection; CFU, colony-forming unit; CHG, chlorhexidine gluconate; CLABSI, central-line–associated bloodstream infections; CP, contact precautions; CRE, carbapenem-resistant Enterobacteriaceae; EKG, electrocardiogram; EMR, electronic medical record; ERAS, early recovery after surgery; HAI, hospital-acquired infections; HCW, healthcare worker; HH, hand hygiene; HIV, human immunodeficiency virus; IBD, inflammatory bowel disease; IC, infection control; IP, infection prevention; IT, information technology; LOS, length of stay; MRI, magnetic resonance imaging; MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-susceptible Staphylococcus aureus; NCI, noncritical items; NDP, nurse driven protocol; PFP, pay for performance; PPE, personal protective equipment; SARS, severe acute respiratory syndrome; SSI, surgical site infection; TSS, toxic shock syndrome; USD, universal staphylococcal decolonization;

UVC, ultraviolet C; VRE, vancomycin-resistant enterococci; WHO, World Health Organization.

Fig. 1.

Virginia Commonwealth University (VCU) Healthcare Infection Prevention Program (HIPP) publications with nonfaculty learners as first and/or second authors in relation to overall HIPP publications.

Table 2.

Descriptive Analysis of Studies Identified

Fig. 2.

Virginia Commonwealth University (VCU) Healthcare Infection Prevention Program (HIPP) publications with nonfaculty physicians as first and/or second authors in relation to overall HIPP publications.

Broad collaborations in infectious diseases research are important given a decline in academic infectious diseases as a career choice. In a 2015 commentary, Edmond and Wenzel explore disturbing trends and challenges in infectious diseases as a career.Reference Wenzel and Edmond ¹⁵ The decline of infectious disease physicians in academic medicine is largely driven by an unbalanced focus on the business model of medicine, highlighting rapid patient transactions linked to professional income with financial incentives for high-volume care.Reference Wenzel and Edmond ¹⁵ This focus is coupled with greater reliance on electronic medical records and the absence of shared physical spaces, such as physician-faculty lounges, for conversation and reflection with colleagues.Reference Wenzel ¹⁶ The result is the primacy of patient volume over value, physician discussion, and/or academic collaboration. The looming shortage of infectious diseases physicians and even fewer hospital epidemiologists further challenges research and patient safety.Reference McCarthy ¹⁷

The time-honored research model is based on grant-funded support, with the faculty member’s time protected, typically >50% of effort, to focus on a specific area of interest. Grant funding further facilitates the hiring of study personnel as investigative assistants and collaborators. Given the priority of relative value unit (RVU) medicine and intense competition for limited funding in hospital infection prevention and safety, a novel approach is required to encourage academic infection prevention work in the current era.

We provide an example of the learning hospital under the framework of infection prevention. A horizontal infection prevention strategy minimizes the cross-transmission of organisms via the most common mechanism, contact.Reference Wenzel and Edmond ¹⁸ In our published studies, we sought to challenge paradigms such as physician attire, the introduction of bare below the elbows, and the use of contact precautions for the control of endemic pathogens, specifically MRSA and VRE. We observed that the discontinuation of contact precautions (CP) for MRSA- or VRE-colonized patients resulted in no significant adverse patient outcomes and drove an institutional practice change.Reference Bearman, Abbas and Masroor ¹⁹ We further explored multiple aspects of the infection prevention program, including the donning and doffing of personal protective equipment, daily and terminal room disinfection, the deployment of touchless UV-C technologies in both acute-care settings and the operating room, hand hygiene, patient chlorhexidine-gluconate bathing, and our antimicrobial stewardship strategies. All of these studies, intended to change perspectives within our institution, frequently resulted in local practice and policy changes. Through our analysis in these studies, we were able to determine whether our interventions had an effect on HAIs in our health system.

In the absence of significant grant funding, the systematic assessment of infection prevention strategies and interventions requires a diverse, flexible, and highly collaborative environment. This process furthers the mentorship mission of academic medical centers. The mentor–mentee relationship is integral to the success of the learning hospital model. This partnership is frequently identified as a “symbiotic” relationship in which both parties have mutually agreed-upon goals with the expectation of gaining further knowledge.Reference Agarwal ²⁰ Through educating the mentee, the mentor is able to enhance their expertise in the field. The mentee benefits through desired career guidance and outcomes.Reference Burgess, van Diggele and Mellis ²¹

By providing mentorship and regular guidance with scheduled project follow-up, the energy, enthusiasm, data-gathering skills, and analytical capacities of nonfaculty learners are harnessed with the explicit purpose of preparing formal abstracts and manuscripts. Some research electives, particularly for medical students, are time limited to 8–10 weeks, requiring greater intensity of oversight.

With increased publication experience and evolving program visibility through novel perspectives in infection prevention, such as healthcare personnel attire and de-escalation of contact precautions for endemic pathogens, opportunities arise for collaborations and publications with colleagues outside of our institution.

Our learning hospital academic infection prevention model has several limitations. Despite the large roster of study collaborators, the minimal grant funding does not allow for long-term, multicenter projects with complicated methodologies and data collection designs. The preponderance of our work has included single center, quasi-experimental studies, observational studies, surveys, and interrupted time-series analyses, all with their inherent statistical and generalizability limitations. Many publications have been small in scope, with limited impact. Nevertheless, output of multiple small publications during the course of a career can result in a significant scholarly impact in toto.Reference Sandström and van den Besselaar ²² Furthermore, our infection prevention program is optimally staffed and supported by our institution, with an associated school of medicine and infectious diseases training program that allows for greater opportunities to explore research topics relevant to our mission. These resources may not be uniformly available to all infection prevention programs.

We are the first to summarize the research experience of an academic infection prevention program under the framework of the learning hospital. Our research is largely focused on multiple aspects of a horizontal infection prevention strategy, antimicrobial stewardship, and controversial areas such as healthcare worker attire, bare below the elbows, and de-escalation of contact precautions for endemic pathogens. Our intent is to critically assess infection prevention strategies and to assess local perspectives and barriers to change policies and practices. The ongoing success of our research mission is based upon the synergy of the infection prevention physician epidemiologists, serving as leaders, mentors, and project managers with motivated college students, medical students, interns, residents, infectious diseases fellows, IP nurses, non-IP nurses, and non-IP HIPP staff. Similar models of diverse research collaboration, in addition to larger, grant-funded initiatives, are needed to further the science of infection prevention in an era of increased demands for healthcare safety.