Discussion

The participants of this study helped identify overarching gaps in two categories. The first is related to audit and feedback practices. The intent of performing clinical audits is to provide a systematic review of healthcare staff performance based on evidence-based guidelines, adherence to recommendations, and may include measures of structures, processes, and/or outcomes of care. ^{Reference Jamtvedt, Flottorp and Ivers22,Reference Hut-Mossel, Ahaus, Welker and Gans23} Feedback from the clinical audit process should provide a clear, constructive, non-punitive message that “directs the professionals’ attention to actionable, achievable tasks intended to improve patient care.” ^{Reference Jamtvedt, Flottorp and Ivers22}

Challenges associated with conducting audits and feedback in CAHs may be associated with human resources availability and knowledge limitations, such as the lack of expertise in developing an audit and feedback program, training staff to perform audits and feedback, and identifying evidence-based guidelines supporting IPC practices and patient care interventions. ^{Reference Johnston, Crombie, Davies, Alder and Millard24} Depending on the size of the CAH, the infection preventionist may be a “team of one” who is responsible for identifying reliable resources to develop specific audit and feedback tools. ^{Reference Rebmann, Alvino, Mazzara and Sandcork25} Access to evidence-based resources, guidance recommendations, and standards may also be a barrier for CAH infection preventionists if purchase-for-access or membership to a professional organization is required. New or inexperienced infection preventionists may not even be aware of existing free resources. Our previous work with 36 Nebraska CAHs during 2015–2017 identified that only 5.5% of CAH infection preventionists were board certified and 19.4% had no IPC training (unpublished data). It is essential for healthcare organizations to recognize the importance of developing a budget to support their program including professional development of IPC team.

The second overarching gap is competency-based training. Competency-based training is a framework for “designing and implementing education that focuses on the desired performance characteristics of health care professionals.” ^{Reference Gruppen, Mangrulkar and Kolars26} Specific performance characteristics identified during an educational program directly translate to outcomes or performance measures utilized in audit and feedback tools. The connection between competency-based training and audit and feedback practices assists in establishing the core elements necessary for a robust IPC program.

Infection preventionists working in CAHs may fulfill multiple roles within the organization, such as employee/occupational health manager, or quality/risk manager. ^{Reference Reese, Gilmartin and Smathers27} Competing responsibilities may diminish the time that can be spent on essential elements of an IPC program including conducting audits and training. Additionally, support services such as secretarial, data, and electronic medical record support may be limited; thus, requiring the infection preventionist to dedicate additional time to the administrative functions of the IPC program. ^{Reference Stone, Dick, Pogorzelska, Horan, Furuya and Larson28}

Majority of CAHs also lacked an efficient drug diversion program. Drug diversion poses significant challenges and has wide-ranging implications including putting patients at risk for healthcare-associated infections. ^{Reference Berge, Dillon, Sikkink, Taylor and Lanier29} Addressing drug diversion requires a multidimensional approach that involves collaboration among IPC professionals, pharmacy departments, human resources, and regulatory bodies. ^{Reference Schaefer and Perz30,Reference Harvin and Weber31} By identifying potential infection risks, implementing robust diversion prevention strategies, comprehensive education and training programs, and establishing robust monitoring systems, facilities can strive to ensure patient safety, healthcare provider safety, and maintain the integrity of the healthcare system. ^{Reference Schaefer and Perz30} Due to their expertise in infection surveillance and outbreak response, IPC programs can play a vital role when drug diversion is suspected and therefore, should contribute to the development of drug diversion program for the facility.

To address IPC challenges in CAHs, we propose several key actions. First, the development and dissemination of tailored IPC guidelines considering CAHs unique limitations, such as limited resources and geographic isolation. Second, implementation of targeted education and training programs to raise awareness, enhance knowledge and skills, and foster a culture of patient safety among healthcare personnel. Third, promoting collaboration and networking among CAHs through regional or statewide communities of practice and focus groups for sharing best practices and innovative IPC strategies. Lastly, ensuring access to technical assistance and resources, including expert consultation, online toolkits, webinars, and support from state health departments, infection prevention organizations, and federal agencies. These actions aim to improve IPC practices in CAHs and enhance patient care.

Small sample size and lack of demographic data from respondents are the major limitations of the study. The very low response rate from two out of four states severely limits the generalizability of study findings. The reasons for variations among state response rates are likely multifactorial. The team that developed and disseminated the survey has longstanding relationships with local public health departments and hospitals across Nebraska and was able to leverage those relationships to encourage participation in this survey. These direct recruitment efforts contributed to a higher response rate in the state of Nebraska. Secondly, we requested public health departments and other stakeholders in each state to assist us in disseminating the surveys and getting the word out. However, it was up to the various partners to choose their own strategy for making the CAHs aware of the survey and encouraging them to participate. Finally, since there were variations in statewide COVID-19 responses in different states, ^{Reference Zhang and Warner32} COVID-19 burden or resource constraints of CAH at the time of the survey in various states may also be different, making them either more or less likely to respond to the survey. ^{Reference Rebmann, Alvino, Mazzara and Sandcork25,Reference Kaufman, Whitaker, Pink and Holmes33,Reference Hoerold, Gottschalk and Debbeler34} The timing of the needs assessment survey could also have had significant implications on the study’s outcomes as it was assessing perceived needs of participants during COVID-19 pandemic and the participants may already have worked on improving various aspects of their IPC programs. ^{Reference Krieger, LeBlanc, Waterman, Reisner, Testa and Chen35} It is interesting that even though the survey was conducted during a pandemic, the response rate for questions related to high-risk pathogens and serious communicable diseases was lower than for questions from other categories. This could be attributed to several factors including limited exposure/experience, lack of prioritization of efforts in this area due to resource constraints, and/or low level of perceived relevance for their setting. ^{Reference Kaufman, Whitaker, Pink and Holmes36,Reference Popescu37} Hence, this study may have underestimated IPC practice gaps in the category of high-risk pathogens and serious communicable diseases and there may be more need for resources in this area.

In summary, this study provided insight into IPC program areas requiring focused attention and resources needed by infection preventionists in CAHs to help improve IPC practices and prioritize resource development and dissemination. Future studies with larger sample size and collection of additional demographic information (e.g. hours spent by infection preventionist on IPC activities, years of experience, facility size, affiliation, and certification) to identify the needs of CAH infection preventionists with various levels of expertise and experience are needed. Studies specifically focused on assessing the needs of CAHs related to safely performing initial assessment and care for patients under investigation for high-risk pathogens and serious communicable diseases will also be helpful. It would also be valuable to explore the relationship between self-assessed gaps and external assessments, such as the Joint Commission surveys, to gain a more comprehensive understanding of IPC practices and their alignment with regulatory standards and guidelines.