Beyond PPE: What Research Reveals About Infection Prevention in Practice

Share this article

During International Infection Prevention Week, NETEC talks with Erica Shenoy, MD, PhD, about what emergency department healthcare personnel can teach us about making infection prevention work in the real world—and why strong everyday practices are also the foundation of high-consequence infectious disease (HCID) preparedness.

Personal protective equipment (PPE) may be one of the most visible signs of infection prevention and control (IPC), but protecting healthcare personnel and patients requires much more than putting on the right gloves, gown, mask, or respirator.

While healthcare environments are increasingly complex and fast-faced, healthcare personnel working in emergency departments additionally face crowded conditions with care delivered in hallways and corridors, suboptimal staffing, high patient throughput, often stark competing priorities, and frequent interruptions. These challenges are further compounded by the very nature of emergency care: when patients present, any infectious risks have yet to be assessed.

Those realities are at the heart of the Journal of Emergency Nursing paper, Beneath the Personal Protective Equipment: Perspectives on Infection Prevention and Control From Emergency Department Health Care Personnel. The study’s co-authors are from Massachusetts General Hospital, home to the Level 1 Regional Emerging Special Pathogen Treatment Center (RESPTC) in Region 1, and brought expertise spanning emergency medicine, infection prevention and control, infectious diseases, critical care nursing, emergency preparedness, and biothreat preparedness. The research team wanted to better understand what helps—and what gets in the way of—frontline personnel putting infection prevention practices into action, in the unique environment of the emergency department (ED).

For International Infection Prevention Week, NETEC spoke with study co-author Erica Shenoy, MD, PhD, Chief of Infection Control for the Mass General Brigham healthcare system and an infectious diseases physician at Massachusetts General Hospital, where she serves as Medical Director of the RESPTC. Shenoy discussed what the team’s findings mean for infection prevention leaders, healthcare organizations, and the frontline personnel who put infection prevention into practice every day.

Knowing What to Do Isn’t Always Enough

One of the clearest messages from the research is that infection prevention challenges aren’t necessarily the result of healthcare personnel not appreciating what infection prevention actions to take to ensure patient and staff safety.

“Staff described what they were supposed to do, for example noting the contact or dwell time for a disinfectant,” Shenoy said. “But all of these pressures—the workload, the crowding, production pressure, and distractions—made the ability to execute really difficult.”

That distinction matters. If a primary barrier isn’t a lack of knowledge, more education alone won’t solve the problem.

Shenoy described a typical experience caring for a patient on contact precautions in an ED hallway recently: she had to find an accessible hand hygiene dispenser, locate PPE, obtain dedicated equipment, and determine where to place precaution signage—each a task on its own—all while assessing the patient and teaching a trainee.

Even for someone deeply familiar and committed to infection prevention, she said, “These tasks, which are much more feasible in other clinical settings, create barriers. It’s almost as if the environment is built to not allow you to do all the things that you know that you need to do to ensure patient and staff safety.”

It points to a larger lesson for healthcare organizations: the physical environments and systems we have established can create barriers for frontline staff to implement infection prevention in everyday workflows.

That was part of the motivation for the research: to hear directly from frontline healthcare personnel about the barriers they encounter and consider how infection prevention strategies could better support them in doing what they already want to do—protect their patients, their colleagues, and themselves.

High patient volume, staffing constraints, hallway care, inadequate space, cognitive load, and competing priorities can all affect whether healthcare personnel can consistently follow recommended practices. That means effective infection prevention strategies must consider human factors, workflows, and the built environment, not just individual behavior.

“If the bed in the hallway is in front of and blocking the hand hygiene dispenser,” Shenoy said, “we shouldn’t be surprised when we see hand hygiene not being performed. These barriers, in this case an actual physical barrier, create extra steps for our staff to do the right thing—clean their hands.”

Looking Beyond PPE

PPE is an essential component of infection prevention, but it is only one part of a broader approach to keeping patients and healthcare personnel safe.

Hand hygiene; cleaning and disinfecting equipment between patients; appropriate patient placement; ready access to supplies; and clear communication about precautions and infectious risks across the care team are foundational. These practices may sound straightforward, but the realities of the care environment can make them difficult to carry out consistently. In the ED, for example, even posting isolation signage can become challenging when patients are moving quickly through the department, receiving care in hallways, or separated by curtains rather than doors.

The question organizations should ask, then, isn’t simply Do our staff know what to do?

It’s also: Have we created an environment in which they can reliably do it?

That means looking at infection prevention from the perspective of the people expected to practice it: Is hand hygiene available where care is actually taking place? Is PPE accessible? Are responsibilities for cleaning shared equipment clear? Can precautions be communicated reliably when patients are in nontraditional care spaces such as hallways and open bays? Do training and workflows reflect what happens during a busy shift rather than what should happen under ideal circumstances?

Listening to frontline personnel can help organizations understand where everyday working conditions create barriers—and identify changes to workflows, processes, or the care environment that make safe practices easier to carry out.

Infection Prevention Is a Team Sport

Strong infection prevention hinges on organizational culture.

Infection prevention teams cannot be at every bedside around the clock. For IPC practices to become part of everyday care, Shenoy said, infection prevention needs to “live within the leadership and frontline” of individual departments. Leaders can reinforce its importance, model expected behaviors, establish individual and team accountability, and create an environment in which every member of the team feels comfortable speaking up about a safety concern.

Just as importantly, organizations need to listen when frontline personnel identify obstacles.

A culture focused on patient and staff safety can help teams move from asking Who failed to follow the process? to asking What made the process difficult to follow, and how can we make it work better?

That shift recognizes that individual vigilance has limits. Healthcare personnel will always play an important role in recognizing risks and speaking up, but safety systems cannot depend on every person catching every problem, every time.

“Vigilance matters, but vigilance alone is neither a reliable or resilient infection prevention strategy,” Shenoy said.

Instead, organizations can design the physical environments of care and workflows that make safe practices easier, more intuitive, and more consistent.

Everyday Infection Prevention Supports HCID Readiness

These lessons become particularly important when considering emerging and high-consequence infectious diseases (HCIDs).

Most healthcare personnel will likely never care for a patient with an HCID or even evaluate a patient with suspected HCID. But many of the skills required for HCID preparedness are the same ones healthcare personnel use in everyday infection prevention: recognizing risk, identifying and isolating a potentially infectious patient, communicating concerns, selecting appropriate PPE, practicing hand hygiene, and managing the environment of care.

“If we’re really good at the basics in infection prevention,” Shenoy said, “then I think we’re just so much more ready and more prepared when concern for an HCID arises.”

Practicing those fundamentals every day helps develop muscle memory around recognizing and responding to infectious risks.

It also gives healthcare organizations continual opportunities to strengthen the systems that support preparedness: evaluating whether workflows function as intended, providing training and education, practicing communication across teams, identifying barriers in the care environment, and refining an organizational culture in which infection prevention and safety are shared responsibilities.

In that sense, everyday infection prevention is also an opportunity to continually practice and improve the foundations that healthcare personnel will rely on when an emerging or high-consequence infectious disease is suspected.

Making Infection Prevention Part of Patient Care

Ultimately, Shenoy would like healthcare personnel to see infection prevention as an integral part of clinical care and their IPC teams as partners in helping to deliver safe care.

She encourages healthcare personnel to think about IPC through the same lens they use to evaluate other clinical risks: What risk does this situation pose to the patient? To other patients? To my colleagues? And what can I do to reduce it?

That risk might come from hands that haven’t been cleaned, equipment that may not have been cleaned and disinfected, a patient who hasn’t been appropriately isolated, or a breakdown in communication. Recognizing the risk and acting on it is infection prevention.

When healthcare personnel understand the connection between those actions and patient outcomes—and when organizational leaders reinforce that connection—IPC becomes less of an “add-on” and more deeply embedded in how care is delivered.

Prevention’s Best Outcome May Be the One We Never See

International Infection Prevention Week is also an opportunity to recognize the people doing this work every day.

Shenoy expressed gratitude both to infection preventionists and to the frontline healthcare personnel who partner with them, emphasizing that each brings knowledge the other needs.

“I think we learn a lot from each other,” she said. “The knowledge that your infection prevention teams share and the partnership they bring is amplified by you at the frontline in everything that you do.”

And there is a challenge inherent in prevention: when it works, its success can be nearly invisible.

“We don’t see the infection, or we don’t see the exposure,” Shenoy said. “It’s hard to link that back to all the actions that we did to prevent it.”

But that “non-event” may be precisely the outcome that infection prevention teams and frontline personnel worked together to achieve.

This International Infection Prevention Week, that is worth recognizing. Effective infection prevention isn’t defined by PPE, a policy on a shelf, or the vigilance of a single healthcare worker. It depends on people, environments, workflows, communication, leadership, and a shared culture of safety.

And when those pieces work together every day, they don’t just make routine care safer. They strengthen the systems and practices healthcare organizations will depend on when they encounter an emerging or high-consequence infectious disease.