AMBER WOOD, MSN, RN, CNOR, CIC, FAPIC, is a senior perioperative practice specialist at the Association of periOperative Registered Nurses (AORN), where she has served as lead author for several AORN guidelines. Wood offers clinical information to members via the AORN Consult Line and contributes regularly to the Clinical Issues column in the AORN Journal. She is a member of the Association for the Advancement of Medical Instrumentation, has served as a liaison to the Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee, and is a fellow of the Association for Professionals in Infection Control and Epidemiology.

Amber Wood, MSN, RN, CNOR, CIC, FAPIC

Infection preventionists and nurses must work together to prevent infectious diseases. (Adobe Stock)

As a perioperative nurse and infection preventionist (IP), I see the struggles that both specialties are facing in practice today. Behind the double doors, perioperative nurses are making do with lean staff and working to advance knowledge on infection prevention practices as they quickly onboard new team members. Operating room (OR) supply shortages are forcing us to consider safe alternatives that still protect patients from infection when critical supplies are running low. On the other side of the double doors, IPs are working across their facilities to balance ongoing COVID-19 vigilance while also responding to the widespread effects of the pandemic, such as a spike in several health care-acquired infections (HAIs) including methicillin-resistant 

 (MRSA) bacteremia. This HAI uptick is putting the infection prevention community on high alert to control further spread of HAIs that could lead to deadly outcomes, including surgical site infection (SSI). Amid these practice challenges, there is one certainty—we can’t face them alone, especially as postpandemic burnout is a stark reality for all of us.

Tackling Infection Prevention Challenges Together

I frequently remind perioperative nurses that infection prevention colleagues are critical allies when it comes to voicing their concerns about infection safety risks. Historically, IPs have worked closely with perioperative nurses in the fight to prevent the spread of transmissible infections to surgical patients. This close collaboration must continue—not only for the challenges we now face, but also for the future infection risks we need to prepare for. The current outbreak of monkeypox provides a perfect example of how we are constantly learning how new and sometimes known but uncommon viral diseases could be transmitted in the perioperative setting to stay ahead of the curve.

From my shared perspective in both practice specialties, I see how collaboration and camaraderie between perioperative nurses and IPs can build resiliency and knowledge on safe practices to reduce infection transmission in the health care setting. Here are 6 key challenges where I see value in perioperative nurses and IPs working together.

Staffing shortages made the top of Emergency Care Research Institute’s (ECRI’s) 2022 list of patient safety risks, in which they cite data such as hospital registered nurse turnover being at 18.7% in 2020. They also note concerns such as age close to retirement as a factor that will only increase nursing shortages in the near future.

 We know the impending worsening of staff shortages is not unique to nursing, as IPs, physicians, and other critical health care positions are also expected to be short-staffed. Such shortages can have lasting effects, affecting patient safety, care disparities, and burnout.

Despite reading these bleak data, some recommendations in the report give me hope. ECRI suggests designing the health care system to be nimble in responding to staff needs

—a perfect opportunity for perioperative nurses and IPs to stand together in voicing such needs, whether those be mental health support or the ability to share patient safety data in a more fluid manner.

Widespread burnout highlights the need for resilience.

Speaking of mental health, the ECRI report also cites startling data on the current state of mental health concerns that spiked during the COVID-19 pandemic response. For example, a 2021 survey of nurses found that 28% demonstrated heightened anxiety during unexpected events.

 If we are being honest with ourselves and our teams, we know that burnout was a reality before COVID-19. Now that the issue is being discussed widely, perioperative nurses and IPs can take this opportunity to foster new ways to connect and support each other for morale, resiliency, and practice safety.

Supply shortage solutions require shared decision-making. 

Supply shortages can pose major risks for infection transmission and other patient safety issues when health care providers are forced to “make-do” with what they have. For example, during the recent shortage of sterile water, which is critical for keeping instruments clean and moist during surgery to facilitate cleaning, OR nurses asked the professionals at Association of periOperative Registered Nurses (AORN) how to sterilize water themselves in the surgical setting. This workaround is not ideal for patients or staff and speaks to the need for ECRI’s recommendation to support “planning, preparation, communication, flexibility, and cooperation with outside collaborators” to safely navigate supply chain disruptions.

 Perioperative nurses and IPs share a foundational understanding in infection control measures in the OR and need to amplify a united voice and evidence-based rationale for discussing safe alternatives to supply shortages with vendors and other facility collaborators.

Increased infection rates demand data sharing.

Recent findings on the state of HAIs flag several key trends that perioperative nurses and IPs should review and track together. For example, Lastinger et al

 analyzed data from the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network and found that standardized infection ratios were significantly higher than those of the prepandemic period and showed increases that spiked in quarters 1 and 3 of 2021, when there was a high number of COVID-19 hospitalizations. Specifically, rates of central line–associated blood stream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), ventilator-associated events (VAEs), and MRSA bacteremia increased. On a positive note, standardized infection rates for 

 infection went down, which was attributed to enhanced surface cleaning during the pandemic. Also, SSI rates did not increase; however, with MRSA bacteremia rates being high in 2021, this common contributor to surgical infection could lead to an increase in SSI that we will see in forthcoming 2022 infection rate data.

The bigger trend I see in these infection rate increases in CLABSI, CAUTI, VAE, and MRSA bacteremia is a clear indication that we have a heavy burden of sick patients who require the central lines, catheters, and ventilators that are associated with these infections. Additionally, consider how staffing challenges are bringing an influx of new nurses into practice who are just learning critical infection prevention practices. Increasing HAI rates also remind us how important it is to be mindful of antimicrobial resistance patterns. The COVID-19 pandemic set us back in many ways, but these setbacks must be temporary, as the CDC reminds us, noting that, “if properly resourced, the US can continue to build resilient public health and health care systems to keep our nation safe from antimicrobial resistance.”

 Collecting and sharing HAI data can help us better understand the HAI realities we face, so we can address them directly for all patients and for overall safety in the health care setting.

Teams must get back to basics with infection prevention knowledge. 

Luckily, we have a wealth of evidence-based knowledge and practice guidance available to show all health care providers how their actions can directly impact HAI rates. For new health care professionals, traveling professionals, and even seasoned veterans, getting back to basics will arm them with the knowledge to make smart practice decisions. In surgical care, perioperative nurse leaders and IPs can present a collaborative review of the basics, such as hand hygiene, sterile technique, and skin preparation to protect surgical patients from HAIs. These recommended best practices and the evidence supporting them are discussed in AORN’s 

and in supplementary guideline implementation resources through the association’s 

 (a member benefit). One important tool in these implementation resources is a gap analysis survey for each guideline to evaluate and shore-up staff knowledge gaps. For example, AORN has been receiving a high number of member questions about sterile technique practices, such as how long a sterile field can be covered. A gap analysis would identify such areas for perioperative nurses and IPs to reteach best practices and share the infection rate data directly linked to those best practices.

Staff instability indicates a need for better team communication.

Beyond infection issues, we know that simply getting staff talking and collaborating within a culture that supports speaking up can significantly reduce risks for patient safety events. As new and traveling team members become acclimated to their current roles, we need to make sure we are fostering healthy communications within a safe environment where all staff feel comfortable raising issues. IPs and perioperative nurses can model team communication by collaborating on any number of critical safety issues that need to be tackled, whether sharing surveillance data on infection rates or partnering to address supply chain concerns. Even common daily pressures to be more efficient in the OR can create patient safety risks that perioperative nurses and IPs can address together.

As perioperative nurses and IPs face the challenges and uncertainties of postpandemic practice, they may feel there is little time to step out of their individual practice bubbles to collaborate. However, taking a moment to chat and recognize shared challenges can fuel fruitful dialogue and lead to new solutions they can implement together. Camaraderie, collaboration, and data sharing are essential to optimize infection prevention as well as morale, and we have a better chance of success if we can work together.

1. ECRI Institute. Top Ten 10 patient safety concerns 2022. Plymouth Meeting, Pennsylvania. ECRI. Accessed September 30, 2022. https://www.ecri.org/top-10-patient-safety-concerns-2022 

2. Lastinger LM, Alvarez CR, Kofman A, et al. Continued increases in the incidence of healthcare-associated infection (HAI) during the second year of the coronavirus disease 2019 (COVID-19) pandemic. 

Published online May 20, 2022. :1-5. DOI doi:10.1017/ice.2022.116.

3. US Centers for Disease Control & Prevention. COVID-19 & aAntimicrobial rResistance. CDC. Updated February 25, 2022. Accessed September 30, 2022. https://www.cdc.gov/drugresistance/covid19.html 

Articles

Infection preventionists and perioperative nurses should collaborate to track and share infection rate data and participate in interdisciplinary workgroups to emphasize patient safety amid burnout and staffing and supply shortages. 

Nurses and Infection Preventionists: An Integral Partnership 

The COVID-19 pandemic thrust everyone deep into the world of infection prevention, probably more than anyone other than an infection preventionist (IP) cared to venture, and kept us all there longer than we wanted to stay. But nurses would be remiss not to take some lessons from this experience to explore what our role is and should be in infection prevention.

The key lesson is that nurses can be effective only when their basic physiologic and safety needs are met. The global disruption in supply of personal protective equipment (PPE) dealt a devastating blow to our safety efforts and eroded the trust nurses have in the system. The reuse 

and decontamination of single-use PPE, although necessary in some dire situations as part of critical strategies to conserve PPE, led nurses to feel they were left unprotected, at risk of infection, and putting their patients at risk of infection and that their respiratory health was at risk from chemical exposure. Nurses who attempted to supply their own PPE were rejected and, in some cases, reprimanded for trying to meet this perceived safety need, which nurses interpreted as a lack of concern for their health.

Although the situation may seem bleak, IPs must identify what went wrong and prevent recurrence to build back trust. To that end, nurses need a seat at the table when discussing PPE stockpiling and purchasing practices to share their lived experiences and help the team discover where practice deviated from plans. IPs should support the nurses in these discussions as allies, informed advisers, and advocates for patient and health care worker safety.

Nurses have been on the front line of the battle against COVID-19 and are often hailed as our first line of defense against infection. However, declaring that nurses are on the front line implies that there is backup on the way. If there is anything this pandemic has taught us, it is that there is no relief crew coming—nurses are our front, back, and only lines of defense regardless of the setting, whether it is the emergency department, inpatient unit, operating room, nursing home, or behavioral health. Because of this, the health and safety of nurses and other frontline clinicians and health care workers must be the top priority if we are going to win the war against pathogens.

We also learned that meeting the psychological needs of nurses is critical to their ability to be effective. Making difficult decisions about PPE management, COVID-19 protocols, and patient care prioritization has taken a toll on the mental health of IPs, occupational health professionals, and health care leaders (Figure). It is essential to acknowledge the impact this pandemic has had on our mental health as we find our path forward.

 Simply seeing the IP in the hallway may trigger a nurse to recall a mixed bag of emotions and traumatic memories of COVID-19 training days that they would rather forget. Offering a forum for peer support and grief counseling can help bridge the divide and move individuals toward healing. Pastoral care can also be a great resource for restoring the emotional well-being of nurses and IPs.

The nurse’s role in infection prevention is also that of an expert adviser. In the earlier stages of the pandemic, elective surgery was canceled across the country. This left a large portion of the nursing workforce being laid off, working at testing centers, or being deployed to other areas of the hospital to support or provide care to patients with COVID-19. The full impact of the delay in elective surgical procedures on patient outcomes may not be known for years. Delays in elective surgery may have led to worsening patient conditions that necessitated an urgent or emergent surgical procedure. The cancellation of elective surgery was also a huge setback to the pocketbooks of hospitals and surgery centers, from which many facilities may never financially recover. In future events, we may see increased resistance to cancellation of elective surgery, and in anticipation of this, hospitals and surgery centers need to start planning now to be prepared to continue surgery safely. This is a prime opportunity to call in perioperative nurses who are skilled in the use of PPE and preventing surgical site infections. The perioperative nurse will be the key partner to the IP for successful planning.

As problem-solving MacGyvers, nurses are the premier implementation experts. IPs can count on nurses for practical advice when implementing new practices and processes. For example, external female catheters have been a game changer as an alternate to indwelling urinary catheters for women to prevent catheter-associated urinary tract infections (CAUTIs). However, there are some practical issues that can be a barrier to implementation, such as leaking. Nurses troubleshoot these issues every day and can provide expert advice for improvement like adjusting the level of suction. When clinicians began placing patients in prone position to improve ventilation because of COVID-19 infections, nurses thrived in the role of implementation experts and patient safety advocates by continuing to support using external female catheters for CAUTI initiatives and also advocated for preventing pressure injuries from the tubing.

Nurses are the portal to the patient and the community. In this position, the nurse’s role is to be a champion and advocate for health and wellness in each interaction. This role is not limited to the nurse’s interactions with a patient. It permeates their being and exists in every interaction they have with family, friends, colleagues, and members of their community. Because of this role, nurses should be a source of credible, evidence-based information, especially in an era of prevalent misinformation and fake news. The IP can support nurses with prepared information on COVID-19 infection, testing, and vaccination in a question-and-answer format to equip nurses with credible speaking points.

It may be difficult to imagine how to begin healing and planning for future events when we are still living in a pandemic. But grief is a funny creature; the more we ignore it, the longer it seems to continue. You cannot just tuck it away deep inside and pretend it never existed. Grief and healing take hard work, but you are not alone. We have a shared experience that bonds us all, for better or for worse. If you are struggling, please talk to someone, and if you are in crisis, get immediate help. Your physical and mental health are of the utmost importance.

AMBER WOOD, MSN, RN, CNOR, CIC, FAPIC, is a senior perioperative practice specialist at the Association of periOperative Registered Nurses (AORN), where she has served as lead author and editor for several AORN guidelines. Wood offers clinical information to members via the AORN Consult Line and contributes regularly to the Clinical Issues column in the AORN Journal. She has served as the AORN staff liaison to the Centers for Disease Control and Prevention's Healthcare Infection Control Practices Advisory Committee, is a member of the ASTM International committee on personal protective equipment, and is a fellow of the Association for Professionals in Infection Control and Epidemiology.

Coping with Stress. Centers for Disease Control and Prevention. Updated January 22, 2021. Accessed March 22, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/managing-stress-anxiety.html

https://academized.com/coping-stress-covid19

COVID-19 Resource Center: Well-Being Initiative. ANA Enterprise. Updated March 23, 2021. Accessed March 25, 2021. 

https://www.nursingworld.org/practice-policy/work-environment/health-safety/disaster-preparedness/coronavirus/what-you-need-to-know/the-well-being-initiative/

Nurses need a seat at the table when discussing PPE stockpiling and purchasing practices to share their lived experiences and help the team discover where practice deviated from plans. Infection preventionists should support the nurses in these discussions as allies.

Amber Wood, MSN, RN, CNOR, CIC, FAPIC

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