Whither Infection Control in Community Hospitals? Musings About the Near Future

The majority of health care in the United States is provided in small, community hospitals, not in large, academically affiliated tertiary care centers. The mean size of hospitals in the United States is 116 beds; 71% have fewer than 200 beds. Of the approximately 5,000 community hospitals in the United States, 40% are classified as rural hospitals. These community hospitals are fighting for survival, and many are losing this fight. According to the American Hospital Association, there are 893 fewer hospitals in existence in the United States now than in 1990. Community hospitals face the same challenges that face all American hospitals. For example, all hospitals face difficulties with financial pressures, growing regulation, public reporting, and increasingly complicated health care. The acuity and impact of these issues, however, are magnified in community hospitals—waves are more likely to capsize rowboats than ocean freighters. Community hospitals also face unique challenges (although one might argue that the term "unique" is not quite the right term, because 70%-80% of all hospitals face the same "unique" challenges). In our view, the 3 most important of these unique challenges are deficits in administrative leadership, lack of specialization, and limited numbers of personnel. In this commentary, we discuss the impact of these issues on infection control programs in community hospitals. In addition, we outline key components of successful programs on the basis of our experience with a network of 39 community hospitals in the southeastern United States. The quality, commitment, and vision of the leadership within community hospitals are key components of any successful infection control program. If infection prevention is not an explicit and actual priority of the administrative leadership in a community hospital, the local infection control program is severely handicapped. Indeed, this administrative commitment cannot be simply made in words—it has to be accompanied by deeds. Unfortunately, turnover of administrative leadership is common and frequent in many community hospitals. In our infection control network of 39 hospitals, 45% of hospitals have changed their chief executive officer (CEO) at least once in the last 3 years. Two hospitals have changed CEO 3 or more times. Time, effort, and "programmatic momentum" are frequently wasted when top leadership changes. Infection control programs are often forced to stall or backtrack when the hospital infrastructure changes with the arrival of each new CEO. Moreover, different CEOs are likely to have varying levels of interest in or knowledge of infection control activities. Even the most supportive CEOs are likely to relegate infection control to a lower priority as they "learn the ropes" in a new position. Second, most community hospitals rely heavily and sometimes exclusively on the volunteer services of busy members of their professional staff to accomplish complex goals related to patient safety, infection control, and quality. Usually, these physicians and surgeons are overburdened with their clinical responsibilities and poorly equipped to provide technical expertise and leadership for infection control initiatives. In our network, only 23% of hospitals have infection control physician-directors specifically reimbursed for their infection control leadership. Furthermore, while 28% of hospitals have infectious disease specialists on staff, few of these specialists have received specific training in hospital epidemiology and infection control or cite infection control as one of their primary interests. In many cases, these infectious disease specialists are either too busy to devote, or not interested in devoting, substantial time and effort to infection control activities—particularly when reimbursement for such work is nonexistent or insufficient. Unfortunately, most community hospitals are not interested in supporting the further training of their personnel in matters related to infection control, even though money spent on such training can yield big dividends for a modest investment. The third unique challenge facing community hospitals is limited numbers of personnel. While the brain (leadership) of community hospitals is often preoccupied with matters unrelated to infection prevention, the heart of infection control programs (the group of infection control professionals