Many factors contribute to the onset of surgical site infections (SSIs) and other healthcare-associated infections (HAIs) while patients are in the operating room, recovery and treatment during hospital stays. Patients are highly susceptible to these infections by nature of this critical care, types of procedures and sterility of equipment, their health status, as well as the surfaces, people and environments around them.
“Truth be told, every hospitalized patient is at risk of acquiring an SSI or HAI simply by receiving medical care or undergoing surgery, and those risks are well documented,” expressed Eric Jungslager, Vice President of Healthcare, GP PRO. “Some of that risk stems from the patient — their age and gender, their tobacco use, their weight or if they have a pre-existing medical condition like diabetes.”
He continued, “Some of that risk is more application-based — the surgical technique that’s used, whether or not catheters are used, and the patient’s length of stay. Of course, there are environmental risks, such as the cleanliness of surfaces, the quality of air filtration and the efficacy of water management systems. And there are risks associated with human contact from both healthcare practitioners and patient visitors — having unclean hands, wearing non-sterile gowns or gloves or failing to wear a mask.”
These infections happen frequently and are life-threatening.
“Infection at the surgical site remains the second most common adverse event occurring to hospitalized patients and a major source of morbidity following surgical procedures,” indicated Shawn Malek, Sales and Marketing Manager, Far UV Technologies, Inc. “Infections are more likely to occur after surgery on parts of the body that harbor lots of germs (or are susceptible to cross-contamination). Surgical site infections have been shown to increase mortality, readmission rate, length of stay and cost for patients who incur them.”
According to Deva Rea, MPH, BSN, BS, CIC, PDI Healthcare, “Some potential procedural-, environmental-, and pathogen-related risk factors would be:
- Emergent/complex procedure
- Preexisting infection/colonization
- Hair removal method
- Skin prep/nasal decolonization
- Antibiotic prophylaxis (timing, choice, dosing)
- Glycemic control
- Blood transfusion
- Aseptic technique/surgical scrub/ gloving
- Skill/technique
- Duration of surgery
- OR ventilation, traffic, equipment/ surfaces.”¹
She added, “Risk factors that are potentially able to be modified are diabetes/glucose control, obesity (BMI >30), smoking, malnutrition and immunosuppressive medications. Unmodifiable patient risk factors include advanced age, recent radiotherapy and history of SSI/ skin infection.”
Repelling infectious agents
Pathogens exist throughout hospitals and healthcare facilities and pose a threat to patients and staff.
“The perioperative environment is an area of high risk for cross-contamination,” emphasized Dana Goossen, MSN, RN, Senior Clinical Consultant, Northeast Region, Ansell Healthcare. “Inadequate cleaning and room turnover procedures put patients and healthcare workers at risk of injury, healthcare-associated infections (HAIs) and surgical site infections (SSIs). The lack of barrier protection in reusable linens exposes patients, increasing the risk for HAIs and SSIs.In addition, there are growing concerns regarding airborne particles and the role it plays in the development of SSIs. Efforts should be taken to reduce debris and particulate in the OR by evaluating materials with lower lint levels.2
Protective barriers on patient beds can help improve patient care and safety, notes Bruce Rippe, CEO, Trinity Guardion, Inc.
“Mattresses are the #2 caregiver touch point in a patient room and a recent SHEA presentation demonstrates 72% of hospital mattresses are not safe, making them a significant patient safety concern. Mattresses routinely come into contact with non-intact patient skin and clinically relevant fluids requiring mid–level disinfection. Contaminated mattresses offer a bevy of transmission modes, such as through the hands of caregivers or wounds from surgical incisions, pressure ulcers, burns, etc.,” he indicated. “Research continues to show that mattresses play a major role in infection risk, a problem that must be addressed to protect patients.”
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Patrick Kammer, Managing Director/CEO, C Change Surgical, adds, “Disruption of sterile barriers can result in contamination. Clinicians have long reported that a single layer of plastic for making sterile ice is not always sufficient.”
Further, Don Lowe, Spokesperson, ProTEC-USA, points out, “Inferior PPE must be considered as a risk when in a surgical site infection (SSI) or healthcare-associated infection (HAI) situation. Too many ‘upstart’ and ‘opportunistic’ sellers of PPE have jeopardized the health of those that wear and those that come in contact with those that wear such poor quality products. (Facilities should) institute and practice a solid strategy and process for assuring sufficient supply of high-quality PPE is available at all times, regardless of the current need or anticipated short-term requirements.”
At Virginia Mason Medical Center, part of Virginia Mason Franciscan Health, their staff keeps a constant pulse on patient infections and safety, stresses, Charleen Tachibana, RN, Senior Vice President for Quality, Safety and Patient Experience.
“As part of our longstanding commitment to quality and safety, Virginia Mason Medical Center has a multi-disciplinary effort focused on preventing HAIs, which can include surgical site infections. Our effort brings together leadership, clinicians and non-clinicians and frontline staff to use evidence-based practices to prevent adverse events, such as central line-associated blood stream infection; catheter-induced urinary tract infection; hospital-onset C. difficile infection; colon surgery site infection; hospital-onset MRSA bacteremia; and abdominal hysterectomy surgical site infection,” she shared. “Also, we will continue to track our success through our comprehensive HAI surveillance methods and performance quality measures. This allows us to document our progress against internal and external benchmarks.”
Fighting antibiotic resistance
Another emerging threat to patients contracting SSIs and HAIs is the medicine used to treat and protect them – antibiotics. They are growing less effective based on several factors.
He continued, “Local antibiotic solutions often use either polymer- or lipid-based formulations. Over the years, neither polymer-based nor lipid-based solutions have individually provided anchored, localized drug delivery at customizable and prolonged release rates needed for healing in critical indications. The key is to find the right formulation that combines the key elements of both solutions.”
Additionally, he explained, “Antibiotic resistance bacteria can be generated following the use of systemic administration of antibiotics, including systemic antibiotics that are given before surgery. COVID-19 has led to an upsurge in the use of antibiotics, further accelerating the development and the establishment of antibiotic resistance bacteria strains in hospitals and therefore raising much concern.”
Joining together to tackle the ongoing antibiotic resistance crisis, “A coalition of organizations representing clinicians, scientists, patients, public health professionals and animal agriculture experts as well as members of the pharmaceutical and diagnostics industries are asking congressional leaders to significantly increase U.S. investments to combat the growing threat of infections resistant to existing antibiotics, and build arsenals of new infection-fighting drugs,” announced Infectious Diseases Society of America earlier this year.
The society added, “At least 35,000 lives in the United States and 700,000 lives globally are lost each year to infections that can’t be treated with available medicines. Drug-resistant infections, which sicken at least 28 million people in the U.S. each year, add at least $20 billion to American health care costs, the letters note, and as much as $1.2 billion globally. Modern medical advances that include cancer chemotherapy, transplantation, cesarian sections and other surgeries rely upon the availability of safe and effective antibiotics…The COVID-19 pandemic, leading to high levels of antibiotic use as well as increased exposure to resistant infections among hospitalized patients severely ill from the coronavirus, also has highlighted the critical importance of controlling antibiotic resistance and developing new antibiotics to be better prepared for future health threats.3
Striving to develop new drug treatments, “A clinical trial to test the antibiotic dalbavancin for safety and efficacy in treating complicated Staphylococcus aureus (S. aureus) bacteremia has begun. The trial will enroll 200 adults hospitalized with complicated S. aureus infection at approximately 20 trial sites around the United States. The trial is being sponsored by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health,”4 reported the National Institutes of Health recently.
The agency continued, “S. aureus is a leading cause of antibiotic-resistant infection. S. aureus infections led to nearly 20,000 deaths in 2017 in the United States, according to the U.S. Centers for Disease Control and Prevention (CDC). This bacterium is of particular concern in healthcare-associated infections. S. aureus bacteremia—an infection of the blood — often requires inserting a central intravenous (IV) catheter to deliver long courses of antibiotics, an invasive procedure that can involve long-term care in healthcare facilities.”
Ensuring surgical safety
What measures can staff take to support sterile equipment, rooms and patients’ bodies during procedures and care?
Trinity Guardion’s Rippe commented, “The Joint Commission recently stated that staff must familiarize themselves with manufacturer’s instructions for use for all medical devices as it pertains to cleaning and disinfection as well as other required preventative maintenance. Mattresses are a semi-critical medical device and represent a significant capital investment. All team members must acknowledge the risk associated with a contaminated environment and recognize their unique role in preventing SSIs and HAIs as well as the impact that improper cleaning processes may have on the expected mattress life. Medical facilities must use the latest peer reviewed research and data to determine if current infection prevention measures are out of date and if new strategies should be employed. Facilities should also consider recommendations and guidelines provided by the FDA and CDC.”
GP PRO’s Jungslager points to other practices staff can take, including, “establishing hand hygiene compliance initiatives, antibiotic stewardship programs and other patient safety protocols that work together to improve patient outcomes. In addition, whether those patient outcome practices are in place or not, I believe that every healthcare worker has a personal responsibility to follow hygiene and infection prevention best practices and guidelines as set forth by the Centers for Disease Control and Prevention.”
In procedural and care areas, Goossen of Ansell Healthcare, adds, “The CDC recommends use of disposable patient-care equipment for preventing transmission of infectious agents.5 Disposable linens and patient positioning straps are two areas where there is an ongoing shift to disposable products to help ensure the safest environment for patients and staff in the perioperative setting.”
Further strengthening infection control protocols is another tactic moving forward, advises Rea of PDI Healthcare.
“The COVID-19 pandemic disrupted healthcare tremendously,” Rea stated. “This undoubtedly caused breakdowns in basic infection prevention practices. Now we are seeing some outcomes of these breakdowns, with increases in HAIs, such as central line-associated bloodstream infections (CLABSIs). Now it is of utmost importance that we arm staff with education and tools to ensure they are well versed in the basic infection prevention practices. To encourage good outcomes and compliance, a robust monitoring of infection prevention processes, along with constructive feedback is also essential.”
References:
1. Anderson, D. J., Podgorny, K., Berrios-Torres, S. I., Bratzler, D. W., Dellinger, E. P., Greene, L., ... & Kaye, K. S. (2014). Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infection Control & Hospital Epidemiology, 35(S2), S66-S88.
2. Dancer S. J. (2014). Controlling hospital-acquired infection: focus on the role of the environment and new technologies for decontamination. Clinical microbiology reviews, 27(4), 665–690. https://doi.org/10.1128/CMR.00020-14.
3. Cross-Sector Coalition Calls for Significantly Increased Investments to Combat AMR, https://www.idsociety.org/news--publications-new/articles/2021/cross-sector-coalition-calls-for-significantly-increased-investments-to-combat-amr/
4. Trial of existing antibiotic for treating Staphylococcus aureus bacteremia begins, https://www.nih.gov/news-events/news-releases/trial-existing-antibiotic-treating-staphylococcus-aureus-bacteremia-begins
5. CDC. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. CDC website. https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf . Accessed on April 25, 2021.
6. Weiner, L. M., Webb, A. K., Limbago, B., Dudeck, M. A., Patel, J., Kallen, A. J., ... & Sievert, D. M. (2016). Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2011–2014. Infection Control & Hospital Epidemiology, 37(11), 1288-1301.
7. Centers for Disease Control and Prevention. “Strategies to Prevent Hospital-onset Staphylococcus aureus Bloodstream Infections in Acute Care Facilities” Available at: https://www.cdc.gov/hai/prevent/staph-prevention-strategies.html
8. Wagner, M., Barnes, C., O’Farrell, E. J., McCauley, S., Walczak-Daege, T. L., & Stringfield, C. (2020). What Is the Impact of Prophylactic Nasal Decolonization in Prevention of SSI?. American Journal of Infection Control, 48(8), S51.
9. Ansell, Data on File.
