Preventing SSIs and HAIs in a post-COVID landscape

As for what hospitals need to know when it comes to preventing HAIs and SSIs in today’s current environment, Cliff Yahnke, Ph.D., chief scientist and head of clinical Affairs for Indigo-Clean and Kenall Manufacturing, said, “Anything that we talk about with an agile to technology is exactly that—agile—it's not a bandage for bad clinical practice. Every hospital has a bundle they put together whether it includes preoperative bathing, with something like CHG. It could be hydration, that type of surgery for more management during the surgery.” 

He continued, “I don't want to put words in the healthcare providers mouth but those are some of the common themes that I see. That's your baseline, that’s what you should be doing. Once you've done that, then it only makes good sense to help disinfect the environment because many studies have shown that we the people, the ones performing the surgery, and the patient themselves, are the largest sources of contributors to bacteria that's in the room. And again, there's numerous studies that show that bacteria contamination in the room influences postoperative outcomes.” 

Lena Fogle, BSN, RN, CNOR, Senior Director Global Clinical Solutions & Procedural Portfolio Marketing, STERIS Surgical Solutions, gave her thoughts on SSIs. She said, “Since the primary cause of SSIs is chiefly attributable to airborne contamination, air quality measures should be an important part of any SSI prevention strategy. AORN now recognizes the importance of managing air quality in the operating environment. This includes, positive pressurization, air exchanges, high-velocity laminar flow as well as air sanitation methods. This ensures that particulates are removed from the air before they have a chance to settle on to instruments and the surgical field where they fall directly into the surgical wound as well as be touch transferred into the surgical site.” 

Speaking specifically about SSIs, Robert Garcia, BS, MT(ASCP), CIC, FAPIC, a microbiology-trained, 40-year Infection Preventionist who is a widely published author and lecturer said, “One of the things that I remember concentrating on, because I covered cardiothoracic surgery for a number of years, is how we would treat wounds postoperatively in those kinds of patients. When you are doing a partial bypass surgery, obviously you are opening the person’s chest and you have a big wound on the patient’s chest. The question is, how do you treat that afterward? The way I looked at that was, you have to implement a process where you’re going to be able to treat that patient with some kind of antimicrobial dressing that’s available on the market.” 

Garcia continued and stressed that whatever choice a facility makes, staff should be taught well and everyone from the bedside all the way to the OR knows know how to use any kind of product like that. He added that it is also important to follow the instructions of the manufacturer. 

A Plan for Disinfection 

According to Erin McLean, Clorox Clinical and Scientific Affairs Specialist, at CloroxPro, a critical first step in preventing HAIs and SSIs is developing a plan for disinfection. “Your plan should categorize disinfection areas by assessing the risk of pathogen transmission. You can then track the surfaces or tools within each area that should be disinfected. Having an organized disinfection plan will also help define roles and responsibilities among the staff. You can outline who's responsible for cleaning specific areas, surfaces, or tools and how frequently they should be cleaned,” McLean said. 

Trent Kelly, Chief Operations Officer at Copper Clean, added, “While active solutions are absolutely essential to SSI/HAI prevention, many are realizing that passive antimicrobial technologies can be a key component to reducing microbial burden and thus reducing HAIs. Since, high touch-point hardware such as door handles, IV poles, and push bars can harbor high microbial loads, and are susceptible to missed cleanings and frequent decontamination, they seem like a good place to start in introducing passive solutions.” 

Looking at today’s healthcare landscape, Angela Newman, senior director of clinical services at Medline, suggested, “The first step is to evaluate the current landscape and understand where there are opportunities for improvement within your facility. The last few years, infection prevention efforts were focused around COVID-19 and some other infections fell to the wayside. For example, healthcare-associated infections (HAIs) spiked during COVID-19 and remain high, according to Hospital Safety Grade data from The Leapfrog Group, with central line-associated bloodstream infections (CLABSIs) showing the greatest increase.” 

She continued, “Infection control procedures have evolved since the beginning of the pandemic. It is important to get a baseline measurement of your staff’s knowledge to help determine training needs. Education is key as infection control procedures cannot be implemented without proper training and many staff members have transitioned roles throughout a hospital over the last few years.”

COVID-related changes in the OR

Yahnke said, “For us, at Indigo-Clean, it never changed our point of view. But for everybody else, it sure did. And it was obviously safety for the patients. Patients would come in with COVID and be there for hours and hours a day. So, hospital workers being around this for hours a day was a big concern. Now, when someone typically goes in for a surgery, they’re screened for various types of diseases of infections in case they don’t want to put them through surgery. If that’s the case, that can be kind of reliable. We’ve all had COVID at some point, many not knowing, so again to call everyone’s attention to focus on something that indirectly helped us, because it raised everyone’s attention to the environment of care. And while some folks may have debated about the environment of care and infectious disease transmission, after that fact, it was just accepted that the environment needs to be clean, and that people can get infected because of it.” 

STERIS’s Fogle commented, “Global events, including COVID-19, have raised awareness around viruses, bacteria and contamination, yet surgical site infections (SSI) remain the most common and costly of all hospital-acquired infections (HAI). As elective procedure volumes continue to normalize post-pandemic, many health systems are exploring advanced technologies in laminar air delivery methods, in-duct or ceiling-mounted air and surface sanitization systems to augment their routine cleaning and decontamination procedures.” 

Amanda Thorton, RN, MSN, CIC, VA-BC, Clinical Science Liaison, PDI West Region, pointed out that, “Despite advances with SSI prevention efforts in previous years, the arrival of COVID-19 made a negative impact on the fight against SSIs. Possible reasons include the fact that for a time, healthcare facilities were overwhelmed with all things pandemic related, diverting both attention and resources away from other infection prevention efforts, which may have led to breaches or lapses in strict SSI prevention adherence. In fact, overall, the landscape of having a surgical procedure has changed since the beginning of the pandemic. Many pre- and post-surgical consults are now done via telemedicine, a practice that is likely to remain a permanent post-pandemic fixture for its ease and convenience for both patient and clinician. A COVID positive test may also lead to that surgery simply being delayed until the patient is cleared (such as in elective surgeries).” 

Copper Clean’s Kelly added, “I think that COVID-19 perhaps changed the landscape of the OR less than sometimes imagined, and has more so given a clear picture of just how vital our prevention methods and practices in the OR are. It has become obvious that good cleanings, practices, and technologies really are vital and effective at reducing contamination and the spread of pathogens.” 

Angela Carranza, manager of clinical resources at Medline, summarized the changes in the OR landscape as, “staffing turnover, surgical supply shortages and OR turnover times.” 

She continued, “As the workforce shortage continues, it has impacted perioperative clinical staff. We are still seeing and feeling supply disruptions impacting the operating room. ORs showed true flexibility in adapting their supply needs throughout pandemic driven shortages, product discontinuations and product modifications. Some ORs have seen a reduction in EVS or assisting staff for room turnovers, leaving clinical teams to shift from caring of the surgical patient to cleaning and preparing the OR suite for the next one. This added stress can place the turnover process at risk and increase the risk of patient cross contamination.” 

Current challenges

Indigo-Clean’s Yahnke commented, “Healthcare is openly constrained by financial resources. That’s something vendors and the public lose sight of. We have resources as a nation that we allocate to healthcare, whether it’s through government or through private healthcare, reimbursement, and so on. That’s a big problem.” 

Robert Garcia added, “What's happened over the last three to four years has been profound. And it wasn't just the occurrence of COVID. I lived through all of those waves of COVID working at the Medical Center and I could tell firsthand of the effects, and I think the first impression was the number of people who left either that had been scheduled for retirement already, or who made a decision to leave. Many of them had a lot of experience in critical care or other bedside capacity, etc. And it wasn't just our end, you had even physicians, you had environmental service professionals, pharmacy people, respiratory. So, it's had a tremendous impact on the industry.” 

As for what organizations should be focusing on now, Garcia stressed support from leadership. “Leadership has to be convinced that they have to put in many more resources into infection prevention,” he said. “If COVID didn’t provide the impetus or show that it was necessary, I’m not exactly sure what’s going to convince them. All of the outside regulatory agencies are not going to relax their reporting requirements, they’re going to enhance them. For example, CMS by next year is going to expand their CLABSI [Central Line-associated Bloodstream Infection surveillance] requirements, going from simple identification of collapses to identification of all causes for bloodstream infections. And that will require an expansion of EMR data.” 

Jim Dacek, Senior Product Manager, STERIS Surgical Solutionscommented, “In recent years, healthcare has addressed room surfaces, hand hygiene, gowning, etc. in the OR, but there hasn’t been much emphasis placed on air as a primary source of contamination. There are several factors related to air quality that should be examined as part of any facility’s SSI prevention strategy including – temperature, humidity, particulate counts, air flow, air exchanges, positive pressure levels, door opens during cases, etc.” 

“Progressive healthcare systems are actively addressing operating room air quality during the design of new construction or renovation projects,” Dacek added. “Using prefabricated single-large diffuser OR air delivery systems such as CLEANSUITE Ceiling System, combined with in-duct hydroxyl generator systems such as PYURE Air and Surface Sanitization System, and Medglas OR Walls that are easy to clean gives innovative health systems a clear advantage in improving air quality.” 

CloroxPro’s McLean added, “Some of the top challenges when it comes to preventing HAIs are the constant evolution of pathogens, coupled with being short-staffed and in turn, having time-strapped employees. In fact, according to Clorox’s 2022 Clean Index Survey, cleaning professionals reported staffing shortages (68%) and burnout amongst staff (52%) as top challenges. As a result, it’s crucial for healthcare teams to receive continued education through quick and effective training. This will help ensure teams are equipped with the tools and knowledge they need to be successful.” 

The future

When asked about the future of this space, Dacek commented, “U.S. healthcare systems will likely follow the recent trend of European hospitals by using prefabricated walls and ceilings in the evidence-based design of their operating rooms. Such materials originate from the cleanroom sector (pharmaceutical and semiconductor manufacturing) because they are durable, easy-to-clean, and install faster than traditional room materials. Prefabricated OR solutions help to create an environment of care that emphasizes patient and staff safety, with the benefits of cost- and energy-efficient installation for the hospital facility.” 

PDI’s Thorton exercised caution in her forecast for the future. “What the future may hold for new SSI prevention efforts is anyone’s guess, but I highly suspect it will have something to do with improving either technique, screening, or surveillance efforts with the assistance of artificial intelligence (AI). In my opinion, anything that can significantly aid in the prevention of such serious infections is worth looking at. On the other hand, the increase of technology may inevitably lead to a rise in ‘invasive’ medical procedures, which are at increased risks for infections. Coupled with rising antimicrobial resistance, the increasing older population, and very little new antibiotics in the development pipeline, there may be a major rise in HAIs contributed to by the use of technology that we have not yet foreseen.” 

Kelly of Copper Clean asserted, “I believe we will see not only an increase in passive procedures and antimicrobial surfaces, like Copper Clean, but we will also see an increase in natural antimicrobials that are reliably effective against superbugs.” 

Fogle wrapped things up nicely, she said, “Facilities should know that they are not alone. Companies with experienced teams and innovative technologies are here to assist facilities and provide guidance throughout the continuum from a new build project, renovation, retrofit or even mobile solutions.”