By Don Sadler
Despite the renewed attention that has been focused on the problem of healthcare associated infections (HAIs) and surgical site infections (SSIs) in recent years, the number of infections occurring remains alarmingly high.
Approximately 300,000 SSIs still occur annually in the U.S., resulting in an estimated 9,000 patient deaths per year. SSIs occur in 1.9 percent of surgical patients and are associated with a mortality rate of 3 percent. Also, 75 percent of SSI-associated deaths are directly attributable to the SSI.
In addition, 800 hospitals will be paid less by Medicare this year due to high infection rates and patient injuries. This is the highest number since the Hospital Acquired Conditions Reduction Program was launched five years ago. Even worse, 110 hospitals are being docked for the fifth straight year.
Achieving a Zero Patient Infection Rate
“While progress has been made in recent years in decreasing HAIs and SSIs, the only ‘acceptable’ number of infections is zero, even if this is a theoretical goal,” says Constance J. Cutler, MS, BS, BSN, RN, CIC, FSHEA, FAPIC, the president and CEO of Chicago Infection Control Inc.
“In my opinion, prevention of infections has always been an important patient safety initiative,” Cutler adds. “If an HAI happens to you or your loved one, you wouldn’t be satisfied with ‘our infection rates are below the national average’ as a response.”
The most common HAIs and SSIs remain staph infections of surgical sites, including infection with MRSA (Methicillin resistant Staphylococcus aureus), says Cheron Rojo, AA, CRCST, CIS, CER, CFER, CHL, clinical education coordinator with Healthmark Industries.
“In addition, endoscope-acquired infections are becoming more common – they continue to be reported in the news and to the FDA,” adds Rojo. “This type of cross-contamination can lead to multiple drug-resistant infections in patients and is associated with high morbidity and mortality.”
Linda Homan, RN, BSN, CIC, senior manager of clinical affairs with Ecolab Healthcare, breaks down the types of HAIs in more detail. According to Homan, pneumonia and SSIs are the most common HAI (21.8 percent each), followed by gastrointestinal infections (17.1 percent).
Meanwhile, Clostridioides difficile (formerly Clostridium difficile) is the most commonly reported pathogen, causing 12.1 percent of all HAIs.
“Surgical site infections result from the introduction of bacteria into the sterile surgical site,” says Homan. “The likelihood that these bacteria will go on to cause infection is impacted by the patient’s co-morbidities, the type of surgery performed, and other factors such as environmental hygiene, normothermia, ventilation, antimicrobial prophylaxis and glucose control.”
Causes of Infections
Rojo says that a common cause of HAIs and SSIs remains improperly cleaned instrumentation and medical devices. “These much-needed surgical tools often have very cumbersome and daunting cleaning, disassembly, testing and reassembly instructions for use (IFUs),” he says. “These IFUs must be carefully followed in order to produce a product that’s safe for patient use.”
According to Deborah L. Spratt, MPA, BSN, RN, CNOR, NEA-BC, CHL, the executive director of perioperative services at University of Rochester St. James Hospital, most SSIs are caused by the patient’s own flora.
“Therefore, it’s important that proper prepping and draping techniques be used in the OR,” says Spratt. “The second most common cause of SSIs is bacteria on the hands of caregivers, so hand hygiene should be performed before gloves are donned and again after gloves are removed.”
At the last facility where she worked, Spratt says she and her infection preventionist worked with a multidisciplinary team on a project focused on decreasing SSIs. “We implemented a bundle that began preoperatively in the surgeon’s office by providing education and CHG soap for showers, along with CHG cloths to wipe the incision site on the day of surgery,” she says.
“In the preop area, we checked glucose levels, kept patients warm and used a CHG cloth again on the site,” says Spratt. “Preop antibiotics began circulating in the bloodstream within an hour before incision and then redosing occurred in the OR as appropriate.”
“We also enforced hair coverage, OR prep using sterile gloves and covered arms and clean closure technique,” she adds.
Spratt is a strong believer in patient education before surgery, on the day of surgery and post-operatively as a key component of reducing infections. “This should include an assessment of the patient’s home environment,” she says. “A home with no running water or a patient with poor personal hygiene will contribute to the infection risk factors.”
Homan says that while emphasis is rightly placed on aseptic technique during surgery to prevent contamination of the sterile field, it’s also important to consider the cleanliness of the environment. “Contaminated equipment and surfaces harbor bacteria that can contaminate the sterile field or the hands of surgical personnel,” she says.
Homan acknowledges that the pressure to turn rooms over quickly between cases is real. “Most perioperative staff members have had no formal training on the process of thoroughly and quickly cleaning and disinfecting rooms,” she says.
“New evidence on the importance of environmental hygiene has been published in the last decade, and professional associations such as AORN and AHE now have evidence-based guidelines for environmental hygiene in the operating room,” Homan adds.
Cutler concurs: “One important thing OR personnel can do to prevent infections is to use external guidelines from AORN, the CDC and other organizations to create their internal policies,” she says. “All health care personnel, including surgeons, should be held to the facility’s policies and be able to speak to and refer to them easily.”
She emphasizes the importance of understanding the chain of infection when it comes to limiting the transmission of bacteria that lead to infection. “The chain of infection explains how bacteria get from the site where they normally live and may cause a surgical site infection,” Cutler says.
“For example, more facilities today are using a product that is applied to the nasal mucosa of any patient with an implant to decolonize patients unknown to be colonized with MRSA,” Cutler adds. “Thorough bathing of patients with CHG cloths kills MRSA on the skin and would also lessen the risk of infection.”
Rojo lists a few other infection prevention steps that he believes could help prevent HAIs and SSIs.
“First of all, the correct cleaning tools, testing equipment and organization tools are needed to ensure clean and functional instrumentation and medical devices,” he says. These include cleaning brushes, laparoscopic testers, multi-pouches and tip protectors.
“Hospitals also need to invest in a more robust inventory of instrumentation and medical devices to meet the realistic demands of the typical day-to-day OR volume,” Rojo adds. “Effective staff communication and education on instrument tray and medical device processing, and the time considerations that go along with them, is also necessary.”
Finally, Rojo stresses the importance of staff training when it comes to infection prevention. “Initial and continuous training with competency verification for sterile processing personnel on both new and existing instruments and medical devices is paramount,” he says.
Zero Tolerance of Infections
Cutler takes a zero tolerance view toward infections and stresses the importance of controlling the things that can be controlled.
“This includes using CHG bathing and following appropriate antibiotic timing,” she says. “These things should be in place and followed 100 percent of the time for every patient, with no exceptions.”