The Live Oak Approach: Lessons from Charleston’s Angel Oak for Infection Prevention

The Angel Oak’s survival didn’t happen by chance. It required deep roots, layered protection, committed advocates, and ongoing stewardship. The same principles apply when building robust infection prevention initiatives in healthcare settings.

Deep Roots: Foundation Through Structure and Commitment

Like the Angel Oak’s expansive underground root system anchoring it through hurricanes and droughts, effective infection prevention starts with a strong organizational foundation. Infection prevention programs must be rooted in leadership commitment and clear infrastructure. Without this, even the most well-designed initiatives will falter under stress.

The Angel Oak was once threatened by a 500-unit development planned nearby. It was saved not by a single policy, but by a community movement—the Angel Oak Effect. Conservation groups, residents, historians, and public officials joined forces to preserve the surrounding land. That kind of coordinated effort is what infection prevention demands. The best programs involve clinical staff, environmental services, administrators, and supply chain managers working in sync toward a shared goal.

Infection preventionists must act as connectors, ensuring infection control isn’t isolated in one department, but embedded across the facility. The foundation isn’t built solely with protocols—it’s built with relationships.

Key Insight: Get the right people to the table early. Executive leaders, bedside staff, facilities teams, and quality improvement professionals must all share ownership of infection prevention goals.

Layered Protection: The Swiss Cheese Model in Action

The Angel Oak’s bark is thick and furrowed. Its branches stretch low and wide, buffering it against wind shear. Its dense leaves repel salt spray. Each layer protects the tree in a different way, and no single defense alone is enough.

This concept directly parallels the Swiss Cheese Model of infection prevention. No single intervention—whether it’s hand hygiene, PPE, environmental disinfection, or device care—can prevent every infection. Each layer has holes. But when implemented together, these overlapping safeguards catch failures before they harm patients.

In practice, this means combining universal decolonization for surgical patients with catheter insertion bundles, chlorhexidine bathing, antimicrobial stewardship, and environmental surveillance. It’s not just about doing more—it’s about doing the right things in tandem.

When Hurricane Hugo battered Charleston in 1989, the Angel Oak lost major limbs but stood firm. It did so not because one part was especially strong, but because its overall structure was layered and flexible. Similarly, when infection prevention programs face COVID-19, Candida auris, or MDRO surges, it’s the sum of defenses—not a silver bullet—that ensures resilience.

Key Insight: Avoid over-reliance on a single solution. Create and routinely reassess a system of layered protections that work together to cover known gaps.

Champions: Sustaining Progress with People

The Angel Oak isn’t protected just by ordinances and fences. It’s protected by people—caretakers, volunteers, and advocates who see its value and defend it. That stewardship model applies directly to infection prevention.

Sustained infection prevention requires more than policy. It requires champions—people who take personal responsibility for advancing the mission. These champions might be a nurse who mentors others on central line care, a facility manager who advocates for water quality upgrades, or a tech in sterile processing who notices and flags process breakdowns.

Programs that thrive long-term don’t just happen. They’re nurtured by staff who are empowered to speak up, spot problems, and offer solutions. The most successful hospitals make infection prevention part of professional identity—not just a checklist.

Key Insight: Infection prevention champions should be formally identified, trained, and supported. Give them protected time, real data, and institutional backing.

Withstanding Erosion: Continuous Improvement and Real-Time Response

Even the strongest roots and the best bark can’t protect a tree forever without care. The Angel Oak loses branches. It’s pruned. The soil is tested. Its caretakers adjust over time.

In healthcare, the natural erosion of compliance is inevitable. Staff change. Habits decay. What worked in 2020 may not work in 2025. Infection preventionists must counter this with Continuous Quality Improvement (CQI). Using iterative models like Plan-Do-Study-Act (PDSA), teams can test small changes, track impact, and adapt rapidly.

One South Carolina hospital applied this during a C. auris outbreak. Instead of waiting for state mandates, they isolated high-risk patients, launched enhanced cleaning with hydrogen peroxide vapor, and conducted active surveillance swabs. The response was quick, data-informed, and adjusted weekly. That’s what stewardship looks like in action.

Key Insight: Build CQI into the DNA of your program. Don’t wait for an outbreak to improve—review, audit, and adjust regularly.

Community and Policy: Protecting the Mission for the Long Haul

In 2023, Charleston officials approved a 44-acre preservation buffer around the Angel Oak. It wasn’t just about saving a tree—it was about codifying values into policy. Infection prevention needs that same institutional support.

Laws mandating public HAI reporting in South Carolina have helped reduce SSI rates and raised the profile of infection control. But internal policies matter just as much. That includes setting minimum staffing levels for infection preventionists, integrating surveillance technology into EHRs, and aligning budgets with safety goals.

Programs fade when leadership turns over or resources shrink. Embedding infection prevention into policy—just like zoning laws protect the Angel Oak—ensures continuity beyond individual champions. Key Insight: Advocate for lasting policy. Use your data and stories to influence system-level decisions that safeguard your program’s future.

Conclusion: Building a Legacy, Not Just a Program

The Angel Oak has survived centuries of hurricanes, urbanization, and human error. Infection preventionists face similar headwinds—new pathogens, resource constraints, and shifting healthcare landscapes. But with deep organizational roots, layered defenses, dedicated champions, continuous improvement, and supportive policy, infection prevention can become just as enduring. As one preservationist put it, “We don’t inherit these oaks from our ancestors—we borrow them from our grandchildren.” The same goes for patient safety. Infection prevention isn’t just about today’s metrics. It’s about building programs strong enough to protect future patients, long after we’re gone.

Call to Action: Build your infection prevention program like the Angel Oak—rooted, resilient, and ready for anything.