Infection Prevention Persists: HAIs still problematic despite surgical advances
by Don Sadler
Many advances that have been made in surgery and healthcare in recent years are truly astounding, which makes it ironic that thousands of patients still die every year from a relatively simple cause — healthcare-associated infections (HAIs).
The statistics with regard to HAIs are sobering: At least two million patients become infected with bacteria that are resistant to antibiotics each year, according to the Centers for Disease Control and Prevention (CDC), and HAIs occur in 5 to 10 percent of all hospitalized patients. Worse yet, HAIs are the fourth leading cause of death in the U.S., with 278 people losing their lives every day from an infection they acquired during their hospital stay.
Increased Awareness of HAIs
If there is any good news in this, it’s that such sobering statistics have resulted in an increased level of awareness about the risks and dangers of HAIs among healthcare professionals. “There is certainly no lack of awareness about the dangers of HAIs,” says Dr. Wallace Puckett, Vice President & General Manager, Healthcare Consumables, with STERIS. “But a hospital, by definition, is a place that will be filled with pathogens because it is filled with sick people. Despite our best efforts, infections find their way into post-op, ICU and the surgical suite.”
Most HAIs, such as surgical wound infections and urinary tract infections, are caused by bacteria normally carried harmlessly on a patient’s own skin, such as Staphylococcus aureus, or intestine, such as E. coli, says Deborah Gardner, MSPAS, OPA-C, CIC, an international scientific affairs and education manager at 3M’s Infection Prevention Division.
“For patients with severely weakened immune systems or in intensive care, infections can come from microorganisms present in the environment, whether inside or outside the hospital,” Gardner says. “Antibiotic-resistant microorganisms like MRSA and ESBL producers are likely to have come from another infected or colonized patient, either via the hands of a healthcare worker or through a contaminated hospital environment where an infected patient has been cared for. These can cause a range of infections.”
Terri Link MPH, BSN, CNOR, CIC, Ambulatory Education Specialist with the Association of periOperative Registered Nurses (AORN), adds that pathogenic microorganisms are becoming more resistant to antibiotics as a result of the inappropriate use of antibiotics.
“The role of the environment in the transmission of pathogenic organisms has been studied extensively,” Link says. “In order for environmental cleaning to be effective, the correct product must be used in the correct way according to manufacturer’s recommendations.”
Good Hand Hygiene Compliance
Healthcare professionals are nearly unanimous in their views about the best way to prevent HAIs: good hand hygiene compliance.
“Unfortunately, appropriate hand hygiene remains a struggle for healthcare workers,” explains Link. “And this is not limited to one discipline — breaches occur on all levels.”
According to the World Health Organization, compliance with hand hygiene standards realizes a 65 percent compliance rate globally.
“So there remains a big opportunity for improvement,” says Gardner.
“Hand washing is the number one and easiest way to prevent HAIs,” says Nancy E. Fellows, MPA, MSN, RN, CNOR, Senior Clinical Education Consultant with Advanced Sterilization Products (ASP). “But with all of the resources available to healthcare workers, being too busy or just simply not thinking about it often prevents them from performing a simple but highly critical task in the prevention of HAIs.”
“The first line of defense should be as simple as good hand hygiene compliance,” adds Gardner. “Incorporating bundles of care can also help lower the risk of infections. For example, one commonly known practice bundle for the OR is CATS: Clipping (vs. shaving); Antibiotics (appropriate administration); Temperature (normothermia); and Sugar (glucose control).”
Environmentally proper surface cleaning and disinfecting can eliminate residual bacteria being transferred from one patient to another, says Fellows. “Those who perform environmental service tasks may feel that their contribution to preventing HAIs is minuscule,” says Fellows. “On the contrary, their knowledge and the proper use of the resources used to clean and disinfect patient areas will provide a safer environment for the patient.”
Gardner says that 3M launched an initiative called OneTogether last year that is aimed at improving patient safety by reducing HAIs.
“OneTogether aims to engage a network of professional associations and industry partners with the goal of driving individual small actions to collectively generate a significant impact on the incidence of HAIs. Supporting associations include AORN, IAHCSMM, SIS and Practice Greenhealth.” Individuals can learn more about the initiative online at JoinOneTogether.org.
Education is the Key
Fellows believes that HAI prevention starts with education.
“Every member of a healthcare system has a responsibility and should be held accountable for patient safety,” she says. “When individuals are not aware that they are doing something that could have an adverse effect on a patient’s safety, the probability of acquiring an HAI is elevated. Providing the correct tools and resources to identify breaches in practice and how to improve upon these practices is critical.”
“Time would be well-spent talking to frontline healthcare providers about what are the barriers to compliance with well-known, standardized behaviors and techniques that we know help prevent HAIs,” says Lena Fogle, Surgical Solutions PeriOperative Consultant with STERIS. “This will help get everyone on the same page.”
According to Fellows, healthcare workers are more likely to comply with HAI prevention behaviors and techniques when they are being observed by a supervisor.
“But infection control practitioners can’t be everywhere at all times,” Fellows says.
Puckett echoed Fellows’ observations.
“We have used direct observation — sometimes referred to as secret shopper — for many years, and we’ve discovered that this helps reduce HAIs. But it’s hard to keep this up, and HAI rates eventually bounce right back,” Puckett says.
Link recommends environmental surveillance to ensure that surfaces are cleaned appropriately and gaps in cleaning do not occur.
“AORN Recommended Practices for Environmental Cleaning are an excellent tool to use in helping to make sure that environmental cleaning is appropriate and effective in the operating room. The CDC Toolkit on environmental cleaning is another excellent resource for conducting surveillance on environmental cleaning,” Link says.
In addition to good hand hygiene practices and environmental cleaning, the following are measures that may also help prevent surgical site infections:
•Appropriate antibiotic use;
•Perioperative glycemic control;
•Maintaining perioperative normothermia;
•Optimizing tissue oxygenation;
•Showering or bathing with soap preoperatively; and
•Preoperative patient skin antisepsis.
New Technology Solutions
As awareness about the risks and dangers of HAIs has risen, new prevention techniques and technologies have been introduced to help reduce HAIs. These include automated room disinfection systems, hand hygiene compliance monitoring systems and new features on medical device sterilization systems like the STERRAD® 100NX® System.
“But reducing HAIs requires a multi-pronged approach,” says Puckett. “Handy hygiene is just part of it. We’re convinced that healthcare workers want to do the right things when it comes to HAI prevention, but workflow systems need to be created and good habits reinforced to help make it happen.”
Focusing on the fundamentals can play a big role in preventing HAIs.
“Getting back to the basics of hand hygiene and cleaning of the environment in healthcare facilities are the two most important and effective ways to decrease HAIs,” says Link.
Puckett notes that there has been a move toward “getting to zero” when it comes to HAIs.
“I don’t think anyone is sure that we can actually get to zero,” Puckett says. “But we can significantly decrease the number and severity of HAIs if we do the right things.”