Stopping CAUTIs, CLABSIs, COVID, and More

Infection prevention prevents the transmission of healthcare-associated infections in patients, staff, and visitors in the hospital setting. The Yale team, led by Medical Director Richard Martinello, MD, professor of medicine and pediatrics (infectious diseases), is frequently concerned with reducing rates of catheter-associated urinary tract infections (CAUTIs), central line-associated bloodstream infections (CLABSIs), ventilator-associated pneumonia, and surgical site infections. Infection preventionists monitor infection rates in the hospital and compliance with precautions such as hand hygiene and equipment sterilization, in addition to undertaking research and providing consultation services for quality improvement.

“A patient comes in and engages with healthcare to improve their well-being. They may, as a complication of the treatment they receive or the environment that they're in, acquire an infection. This is what we aim to prevent,” said Martinello.

Martinello oversees infection prevention for Yale New Haven Health (YNHHS). Scott Roberts, MD, assistant professor (infectious diseases) and associate medical director of infection prevention, and Thomas Murray, MD, PhD, associate professor of pediatrics (infectious disease) and associate medical director of infection prevention, handle adult services and pediatrics respectively at Yale New Haven Hospital (YNHH). The three-person team works closely with infection preventionists across all YNHHS locations.

“We help our sophisticated programs, like surgery, oncology, even primary care, stay on that cutting edge while doing so in a safer manner, which optimizes the outcomes of our patients,” said Martinello.

In the face of COVID-19, the infection prevention team’s efforts were critical. They started by designing several new policies. “The adult hospital went to a no-visitor policy,” said Murray. “On the children’s side, we adjusted it and allowed a child patient plus one caregiver.”

Additionally, the team gave directives which introduced masking, vaccine requirements, and contact tracing for staff and patients. Infection prevention also worked with YNHHS Supply Chain, Occupational Medicine, and Yale Medicine leaders to ensure personal protective equipment (PPE) availability and that PPE met quality standards.

Across the healthcare enterprise, infection preventionists put COVID-19 policies into operation. “They are the unsung heroes of this pandemic. Every time a protocol changes or someone thinks they have COVID, infection preventionists are the ones who talk to them,” said Murray.

On top of policymaking, the team prioritized communication with staff and the public. When people had questions, infection prevention helped develop a COVID-19 call center with infectious disease clinical staff. The call center was an important resource for employees, patients, and visitors as policies changed to keep up with public health concerns.

“The biggest lesson I’ve learned is to look at problems from all sides. With or without COVID, how do we protect them? How do we isolate them, what is the air flow we need in the room, what PPE is required for the patients and the staff?” said Roberts.

Now, the infection prevention team finds itself equally responsible for reducing rates of COVID-19 and other hospital-acquired infections. “We are always trying to think about how we can do things better. In handling the pandemic, we're lucky in the sense that we've always been a very mission-driven group,” Martinello said.

The team highlighted their efforts in the JAMA Internal Medicine paper, “Analysis of Failure Rates for COVID-19 Entrance Screening at a US Academic Medical Center.” In the paper, the authors reviewed failure screening rates for the 951,033 people who attempted to enter YNHH from March 2020 to May 2021.

The team found a low incidence of screening failures. Failures peaked during the first wave of the pandemic and declined significantly in the subsequent months. As failure rates decreased, maintaining entrance screening necessitated high costs in exchange for limited benefits. After the purchase of supplies and compensation of staff, the team estimated a minimum cost of $2350 to identify a single failed screening across the entire study.

Besides conducting screenings, staff ensured every patient adhered to masking policy. A high proportion of visitors entered wearing inadequate face masks, such as cloth masks. Staff provided patients with masks, which may have mitigated the spread of COVID-19.

In addition to Martinello and Roberts, other authors include Ridwan N. Faruq, MBBS; Anne K. Wilkinson, MBA; Dinesh S. Pashankar, MD, MBA; Mark Russi, MD, MPH; and Babar Khokhar, MD, MBA.

Read more in “Analysis of Failure Rates for COVID-19 Entrance Screening at a US Academic Medical Center.”

Richard Martinello, MD

Martinello encountered infection prevention as a resident at Indiana University. “It struck me that about half the patients we were consulting were suffering from healthcare-associated infections,” said Martinello. Shortly after, he joined a combined medicine and pediatrics fellowship at Yale School of Medicine where he studied hospital epidemiology.

This background propelled Martinello into an administrative position at the VA Connecticut Healthcare System. He developed infection prevention policies and emergency preparedness plans for the West Haven location.

When the H1N1 flu pandemic hit in 2009, Martinello moved to Washington, D.C. to lead the VA’s Influenza and Influenza Prevention Program. As the pandemic subsided, he continued working in the capital as the chief consultant for the Clinical Public Health Group. In this role, he led teams performing public health and infection prevention investigations, VA’s program for HIV and hepatitis C virus, tobacco issues and infection prevention communications.

In dealing with national public health challenges, Martinello served on several White House committees and presented at the National Academy of Sciences. “My six years in Washington were an amazing opportunity to collaborate with other federal departments and agencies to develop policies that not only impacted VA Connecticut and other VAs but also had a broad beneficial impact on public health across the U.S.,” said Martinello.

Martinello returned to Yale as the medical director of Infection Prevention in 2015.

Scott Roberts, MD

As a kid, Roberts was drawn to medicine because he loved biology and wanted to help others in times of need. Roberts graduated from Albert Einstein College of Medicine and completed a residency at University of Michigan. Roberts encountered healthcare-associated infections during his fellowship at Northwestern Memorial Hospital in Chicago.

“As chance would have it, our hospital along with several other facilities around the city and the state, were dealing with an outbreak of Candida auris,” recalled Roberts. “I got thrust into the epidemiologic side, which included screening people at entrances, testing patients, and reducing spread within the hospital,” Roberts added. With a newfound interest in infection prevention, Roberts’ final research project consisted of a genome sequencing of isolates from cultures of patients.

Roberts joined the Yale Infection Prevention team in 2020, just after the first wave of the COVID-19 pandemic. “I got the chance to see how COVID is managed in another health system at a different phase of the pandemic. Under Rick’s mentorship, I’ve learned how different people handle infection prevention,” said Roberts.

Thomas Murray, MD, PhD

After receiving his MD and PhD from University of Connecticut, Murray completed a pediatric residency at YNHH. He stayed at Yale, completing concurrent fellowships in pediatric infectious diseases and medical microbiology. After conducting similar work at Connecticut Children’s Hospital, Murray joined the Infection Prevention team in 2018.

At Yale New Haven Children’s Hospital, Murray creates infection prevention policies specific to children. “From an infectious disease perspective, some diseases are the same, but kids often present differently, and because of their different ages and different risk factors, there are some diseases that are more severe in kids than in adults,” according to Murray.

“I feel very fortunate that the people in Infection Prevention are exceptional. Being able to see our group pivot to deal with a pandemic and everything that goes with it over the last two years, in addition to all the regular infection prevention work that doesn't stop, has been really remarkable,” Murray said.

The team has embarked on a new project to test how new approaches in infection prevention work to improve patient safety and education in partnership with the Centers of Disease Control.

“For one part of our effort, we are now exploring the use of ontologies, building information models, and human factor analysis to identify factors in hospital building design and healthcare staff workflows which may be changed to decrease risk for patients to develop a central line associated bloodstream infection while hospitalized,” said Martinello, who serves as the principal investigator.