Discussion

In this quality improvement intervention characterizing the implementation of a CSIP program at 12 acute care facilities, we identified several major themes: LIP time and efficiency spent performing surveillance was more variable than CSIP time and efficiency. Both LIPs and unit directors perceived significant improvement in LIP ability to reduce infection-related patient harm after adoption of CSIP. These observations are a substantial contribution to the published experience of centralized surveillance. They will be important to multiple-facility health systems considering a centralized model for HAI surveillance, and they describe a model that may improve patient safety in acute care settings. ^{Reference Barnes, Zirges and Tomac9,Reference Le Goff, Smathers, Satchell, Handy and Sammons15}

When reporting on LIP and CSIP efficiency and activities, there are some limitations. There are no robust measures of time and efficiency; efficiency was lower than we anticipated for CSIP infection preventionists and more variable than we anticipated for LIPs. We believe that focusing work activity on the surveillance task provides our organization with a more reliable and accurate HAI reporting system. Anecdotally, LIPs reported that HAI surveillance was often sporadic (eg, concentrated and rushed to meet a reporting deadline), which may account for spikes in efficiency rates. LIPs still review reported HAIs and are in close communication with CSIP infection preventionists about time-sensitive findings. Future studies should investigate whether LIPs vs CSIPs have more “accurate” HAI reporting. Additionally, CSIP programs may have a better ability to detect transmission involving multiple facilities, although we cannot yet evaluate that.

With implementation of the CSIP program, LIPs saw greater opportunities to effect change with less of their time allocated to HAI surveillance. However, LIPs reported unchanged or lower satisfaction with professional goals and sense of rewarding work after CSIP implementation. This finding contrasts with the responses of unit directors, which reported similar or improved opinions of LIP work after CSIP implementation. We attribute this reported dissatisfaction to the dramatic change in their roles after CSIP implementation. LIPs content with technical HAI surveillance work no longer had this work that they had perceived as gratifying, and many LIPs did not feel fully prepared to play a more prominent role in quality improvement work or to be responsible for seeking innovative solutions. The ongoing COVID-19 pandemic also prevented the collection of a larger survey cohort for LIP and UD surveys, or repeated surveys. However, overall, organizational assessment of the CSIP program in our health system has concluded that it is a positive change to HAI surveillance and reporting.

With the evolving role of infection preventionists, levels of work-related stress may be rising. CSIP programs may allow them to focus on the interdisciplinary and outcome-oriented activities, which may in turn improve effectiveness and job satisfaction. ^{Reference Conway, Raveis, Pogorzelska-Maziarz, Uchida, Stone and Larson16} Because of the perceived benefit of CSIP programs and the data observed in these analyses, we continued to expand our CSIP program to more facilities in our healthcare system and consider it a valuable and necessary part of our infection prevention strategy. Evaluation of CSIP perception of program success is ongoing, switching from evaluation of efficiency and perceived effectiveness to correlating adoption of centralized surveillance with infection-related patient outcomes. Although we are not reporting CSIP job satisfaction, to date CSIP employee retention in our program is very high: through 2022, 5 of 6 CSIPs have remained in the role, with 1 employee transitioning to infection prevention management within the organization. Reduction in HAI is the ultimate objective of this new model of HAI surveillance and LIP work structure.

This investigation had additional limitations. The time spent performing surveillance was self-reported and may have been subject to recall or reporting biases. Surveillance efficiency may have been affected by the complexity of patient cases and distribution of medical conditions, which was not reflected in the summary estimate of efficiency presented here. However, an established measure of HAI surveillance efficiency has not been established. For this analysis, we did not measure the accuracy of HAI surveillance, which may affect the interpretation of time and efficiency findings.

Implementation of a CSIP program leads to more uniform HAI surveillance practices and presents an operational challenge in that selecting strong CSIP candidates and transitioning LIPs to a different role is required. We cannot yet conclude on the effect of this model to improve patient safety. Adoption of centralized surveillance programs have not been widely reported, and there is no accepted approach for doing so. Based on our experience, we provide insights for health systems planning adoption of centralized surveillance (Supplementary Appendix Box). CSIP team members may be empowered to play a role informing and potentially overseeing HAI prevention in multiple facilities. As health system centralized infection prevention-related processes are increasingly implemented, the quality and safety community should maintain a focus on the goal of safe and effective healthcare. In this evaluation, we have begun to explore the hypothetical benefit of centralized surveillance on HAI reduction, but more robust and causal analyses are needed.

The volume and complexity of the infections encountered in centralized surveillance is often not appreciated by the new CSIPs until they receive a full assignment. CSIP staff members are provided with resources and training specific to their roles that emphasizes their previous infection preventionist experience. (For a detailed summary of CSIP onboarding and resources used at our institution, see the Supplementary Appendix.) New CSIP staff members are partnered with another CSIP to be a resource for frequent check-ins and questions and to assist with the volume of work. With a variety of facilities and patient populations across the health system, assignments are balanced in both complexity and volume. The entire department provides peer review of HAI surveillance, documentation, and reporting; monthly calls review areas for improvement, review individual work volume, and highlight successes.

In this quality improvement project report, we demonstrated that a CSIP program for HAI surveillance eases the burden of surveillance on LIPs, allows for increased LIP job satisfaction, and allows for a more stable rate of surveillance and HAI reporting. Future investigations should continue to characterize in these and other novel ways the potential for CSIP programs to improve infection-related patient safety.