Health care–acquired infections (HAIs), also called nosocomial infections, are 1 of the top 10 leading causes of death in the United States.

 HAIs cost hospitals billions of dollars each year, which reduces profitability. Historically, HAIs were considered an acceptable risk of hospitalization until evidence proved that most were preventable.

In the past decade, governments began holding hospitals accountable for preventable HAIs. Although most states passed laws requiring hospitals to report infections, many failed to do so.

 The Leapfrog Group, a health care safety organization, recently released Hospital Safety Grades for 2900 facilities,

 which represents less than half of all US hospitals. Consequently, the true scope of HAI impact is likely much greater than we know.

Social and economic factors play a major role in the prevalence of HAIs. Health care organizations face time, staff, and budget constraints that make it difficult to expand HAI mitigation programs. There are many more hospitals that have severely limited resources and suffer overcrowding, insufficient supplies, and lack of proper training.

 Yet, the cost of reacting to contain HAIs and the resulting loss of lives is far greater than the cost of more proactive infection prevention practices.

Meanwhile, during the 2 years hospitals were focused on COVID-19, nosocomial infections thrived.

 Conceivably, if health care facilities applied the same pandemic-level effort toward HAI mitigation, significant reductions in HAIs might be achieved on a wider scale.

HAI mitigation begins with knowing the pathogenic enemies and where they live. The most common HAIs fall into 6 categories: central line–associated bloodstream infections, catheter-associated urinary tract infections, surgical site infections, ventilator-associated pneumonia, nonventilator-associated hospital-acquired pneumonia, and gastrointestinal 

Although nosocomial infections are a serious concern in health care, more urgent threats exist. HAIs have been linked to antimicrobial-resistant and multidrug-resistantorganism (MDRO) infections, which are unaffected by 1 or more antibiotic, earning the moniker 

 The 5 superbugs that contribute to most HAIs are: methicillin-resistant 

, carbapenem-resistant Enterobacterales, 

). Long-term care settings are particularly vulnerable to HAIs and MDROs, namely 

It is important to understand the basic pathogen characteristics that enable them to survive and spread. For example, 

 forms spores that persist on floors and surfaces and are difficult to destroy,

colonizes skin and can pass from person to person or shed onto surfaces. MRSA and 

 often survive in protective biofilms, making them harder to eradicate.

Understanding the transmission ecosystem is the next step toward mitigating HAIs. It is a complex mix that involves infectious agents, patient susceptibility, and infection control practices. The source of the infectious agent is the first link in the chain of infection. Hence, the key to breaking the chain (

) is to address the source and disrupt its transmission.

The 3 primary modes of HAI transmission are aerosol (airborne), droplets, and contact.

However, some pathogens are transferred by more than 1 route. Although the pandemic targeted mitigation efforts on aerosol transmission, it diverted attention from other modes, which likely contributed to increases in HAIs.

According to the Centers for Disease Control and Prevention (CDC), environmental contamination is one of the highest-risk routes for transmission of the most prevalent nosocomial infections.

 Microbiologically contaminated surfaces (fomites) serve as reservoirs

 that allow pathogens to survive for hours, weeks, or even months.

Transmission via fomites begins when inanimate objects are contaminated by an individual, droplets, or, in the case of 

 Indirect transmission occurs primarily through hand contact with fomites. Microbes are then transmitted to a person who can become infected and transfer to another person.

This scenario illustrates a complex chain of infection, connecting the infectious source to the patient.

Studies have established that cross-transmission in the hospital environment is primarily because of contaminated surfaces (

Research found that between 23% and 100% of the noncritical medical items were contaminated, up to 80% of them with pathogenic organisms and up to 25% with MDROs.

 Another study showed gloves did not prevent contamination or stop the spread of infections

 yet, approximately 30% of HAIs have been attributed to the contaminated hands of health care personnel.

In the past, hospital floors were not viewed as high-risk surfaces, but that has begun to shift. Floors are a primary transmission route for 

can be picked up on shoes and carried throughout a facility.

Understanding pathogenic transmission modes is crucial to disrupting the chain of transmission, not only for specific diseases but also for other pathogens that follow a similar route.Reducing environmental risks for HAIs depends on implementing protective barriers along the path of transmission between microorganisms, the environment, and individuals.

The CDC identified 17 high-touch surfaces with frequent hand contact that must be addressed when conducting daily and terminal cleanings in patient rooms.

 Unfortunately, studies have shown that less than 50% are effectively cleaned and disinfected with a sporicidal.

 Best practices for minimizing infection risk include cleaning and disinfection of allpatient care areas (

), as well as floors and all noncritical medical items used across the continuum of care.

A foremost consideration in infection prevention and control (IPC) programs is choosing a disinfectant with ideal properties.

 Customary cleaning products widely used for hospital disinfection do not always address the most urgent threats, and those that do often have hazardous adverse effects. For example, quaternary ammonium compounds are not effective against 

 and, although sodium hypochlorite (bleach) and peracetic acid (PAA) have 

 any efficacy is offset by associated health hazards. Alternatively, hydrogen peroxide may be less toxic and work on 

 claim. Moreover, of the aforementioned chemistries, only PAA has a biofilm claim but is an extremely hazardous chemical. The optimal approach is to utilize a broad-spectrum disinfectant with claims against all urgent threats and biofilm, as well as an ideal safety profile.

Another important consideration is preventing incidence of cross-contamination, particularly when working within time constraints. Terminal cleans can be executed more efficiently and effectively with touchless electrostatic sprayer technologies and, when combined with disposable wipes, more thorough disinfection can be achieved without recontamination.

Nonetheless, disinfection interventions on environmental surfaces are only 1 component in a larger system of IPC strategies. It is critically important that health care facilities take a system-level approach to reducing HAIs.

Mitigating HAIs requires a holistic approach to infection prevention that encompasses knowledge of all links in the chain of infection and layered interventions. Sustainability of interventions and program compliance are reliant on multimodal strategies that incorporate monitoring/auditing and prioritize ongoing education of current and incoming staff.

Standardization has also become vital to the reduction of HAIs. Standardizing cleaning products and protocols simplifies processes, raises compliance, and creates universally effective IPC measures.

Reducing HAIs is everyone’s responsibility. All interprofessional health care team members have a stake in the process. Gaps in environmental control can be identified by anyone, from infection prevention and facility management to housekeeping. Incorporating multidisciplinary risk assessments, education, and compliance monitoring will allow for 360° surveillance and a greater ability to disrupt transmission of HAIs.

1 Statistics on HAIs. Healthcare Surfaces Institute. 

https://www.healthcaresurfacesinstitute.org/statistics-on-hais/

2 McCaughey B. Unnecessary deaths: the human and financial costs of hospital infections. 3rd Edition. Committee to Reduce Infection Deaths (RID). 

https://www.hospitalinfection.org/ridbooklet.pdf

3 Hospital Infection Reporting. Committee to Reduce Infection Deaths (RID). 

https://hospitalinfection.org/resources/state-infection-laws/state-law-summary/

4 Record number of hospitals receive an ‘A,’ ‘B,’ ‘C,’ ‘D,’ or ‘F’ on the Leapfrog Hospital Safety Grade. Hospitalsafetygrade.org. November 10, 2021. 

https://www.hospitalsafetygrade.org/about-our-movement/newsroom/display/1020887

5 Health care-associated infections fact sheet. World Health Organization. 

https://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf

6 Weiner-Lastinger L, Pattabiraman V, Konnor R, et al. The impact of coronavirus (COVID-19) on healthcare-associated infections in 2020: a summary of data reported to the National Healthcare Safety Network. Cambridge University Press. September 3, 2021. 

https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/impact-of-coronavirus-disease-2019-covid19-on-healthcareassociated-infections-in-2020-a-summary-of-data-reported-to-the-national-healthcare-safety-network/8197F323F4840D233A0C62F4726287E1#

7 Abdullah M. 5 most common hospital acquired infections (HAIs). Inivos, January 28, 2021.

https://inivos.com/blog/5-most-common-hospital-acquired-infections-hais/

8 Monegro A, Muppidi V, Regunath H. Hospital acquired infections. 

https://www.ncbi.nlm.nih.gov/books/NBK441857/

9 Preventing healthcare associated infection (HAI). Victoria State Government Department of Health. 

https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/infections-in-hospital-reduce-the-risk#types-of-healthcare-associated-infection

10 Dyer J. IP strategies for mitigating spread of candida auris. 

https://www.infectioncontroltoday.com/view/strategies-for-mitigating-spread-of-candida-auris

11 Curless M, Forrester L, Trexler P. Reference manual for health care facilities with limited resources: Infection prevention and control. Module 1. Introduction to infection prevention and control. Jhpiego, Johns Hopkins University Affiliate. May 20, 2020. 

https://www.c19hub.io/module-1-introduction-to-infection-prevention-and-control/

12 Homan L. The critical role of environmental hygiene in the prevention and control of candida auris. 

https://viewer.joomag.com/healthcare-hygiene-magazine-september-2021-september-2021/0280572001631046038?page=48

13 Higgins E, Connors B. The need to understand infection risk sources and pathways to mitigate HAIs. 

Patient Safety & Quality Healthcare (PSQH)

https://www.psqh.com/analysis/the-need-to-understand-infection-risk-sources-and-pathways-to-mitigate-hais/

14 Clinical educators guide for the prevention and control of infection in healthcare. Australian Commission on Safety and Quality in Healthcare, National Health and Medical Research Council. 

https://www.nhmrc.gov.au/sites/default/files/documents/attachments/publications/icg-clinical-ed-guide.pdf

15 Healthcare-associated infections (HAIs) introduction: Best practices for environmental cleaning in healthcare facilities: in RLS. Centers for Disease Control and Prevention. April 22, 2022, 

https://www.cdc.gov/hai/prevent/resource-limited/introduction.html

16 Infection prevention and control (IPC) for COVID-29. National Centre for Disease Control India. April 3, 2020. 

https://ncdc.gov.in/WriteReadData/l892s/53436598731586345131.pdf

17 McCaughey B. RID guidelines for reducing the risk of candida auris. Committee to Reduce Infectious Deaths (RID). 

https://hospitalinfection.org/about/candida-auris/

18 Surfaces & HAIs FAQ. Healthcare Surfaces Institute. 

https://www.healthcaresurfacesinstitute.org/surfaces-and-hais-faq/

19 Doll M, Bearman G. Guide to infection control in the healthcare setting-New technologies in infection prevention. International Society for Infectious Diseases. January 2018. 

https://isid.org/wp-content/uploads/2019/06/ISID_GUIDE_NEW_TECHNOLOGIES_INFECTION_PREVENTION.pdf

20 Johnson L, Nutt A, Piatek D, et al. Strategies to mitigate cross contamination of non-critical medical devices. Association for Professionals in Infection Control and Epidemiology. 

https://apic.org/noncritical-is-critical/#:~:text=Rutala%20and%20Weber6%20have,in%20environmental%20services%2C%20patient%20equipment%2C

21 Preventing healthcare associated infection (HAI). Victoria State Government Department of Health. 

22 Teska P, Gauthier J. Floor hygiene and the under-studied risk of pathogen dissemination. GBAC, TIPS. Infectioncontrol.tips. June 9, 2021. 

https://infectioncontrol.tips/2021/06/09/floor-hygiene-and-the-under-studied-risk-of-pathogen-dissemination/

23 Environmental checklist for monitoring terminal cleaning. Centers for Disease Control and Prevention. 

https://www.cdc.gov/hai/pdfs/toolkits/environmental-cleaning-checklist-10-6-2010.pdf

24 Rea D, Healthcare Associated Infections & the Environment: Mitigating Risk with Environmental Control Strategies, Healthcare Facilities Today, June 18, 2018, 

https://www.healthcarefacilitiestoday.com/posts/Healthcare-associated-infections-the-environment-Mitigating-risk-with-environmental-control-strategies--18670

25 Christenson E, Cronk R, Atkinson H, et al. Evidence map and systematic review of disinfection efficacy on environmental surfaces in healthcare facilities. International Journal of Environmental Research and Public Health (IJERP). October 22, 2021. 

https://pubmed.ncbi.nlm.nih.gov/34769620/

Articles

Time, staff, and budget constraints make it difficult to expand HAI mitigation programs despite the obvious and urgent need to do so.  

Environmental Measures Disrupt Transmission of HAIs

Cleaning and disinfection are critical and will always be an essential focus as health care professionals work to mitigate the spread of health care–acquired infections (HAIs). Yet, as new advances in disinfectants and disinfection technology continue to emerge, an overlooked issue continues to intensify and must be addressed.

Surface material and product damage caused by surface disinfection incompatibility impedes effective cleaning and disinfection, costs health care facilities millions of dollars annually, and creates dangerous safety issues for patients and health care personnel. There are many different materials and textiles within a health care facility, and they cannot all be cleaned and disinfected the same way. When they are, damage occurs. First, at a microscopic level, and then it continues until the damage is clearly visible.

It is impossible to deal with a microbial issue at a macro level. We all know microbes can’t be seen. Visual inspections following disinfection do not provide information about what remains on and in surfaces at a microbial level. Surface damage caused by incompatible disinfection methods—cracks, fissures, and pits—provides microscopic reservoirs for microbial attachments, colonization, and biofilm formation. This provides pathogens a potential safe harbor away from the biocides used to disinfect the surfaces, placing patients and health care personnel at risk for contracting infections.

Many factors influence microbial attachment. It is critical to have a basic understanding of what can remain on surfaces after cleaning and disinfection. Well-documented research provides insight into the role surfaces play in acquiring and transmitting microbes that cause deadly infections. In a February 2021 

, Zheng et al describe in detail how microbes attach to surfaces.

Surface damage can support microbial attachment, colonization, and ultimately, biofilm formation. Biofilm is a complex matrix of extracellular polymeric substances that protect against environmental adversities. Once biofilm is formed, killing the bacteria or removing the biofilm that protects them is extremely difficult, as is disinfecting damaged surfaces where microbial reservoirs have been created. The selection of surfaces that are compatible with disinfectants used in the health care setting is critical during the design of products or the built environment.

A Case Study on Surface Disinfection Incompatibility

Because of the complexity of this problem, many facilities pay high costs for repair, replacement, and ongoing maintenance for medical equipment. In many cases, the cause of the problem is overlooked. In a jointly released case study,

 the Healthcare Surfaces Institute (HSI) and the Association of Healthcare Value Analysis Professionals conducted a deep-dive analysis to understand the root cause of damage to a medical device.

A large midwestern hospital, with approximately 700 licensed beds and over 1.2 million patient encounters yearly, purchased several hundred state-of-the-art, noninvasive optical sensor medical device monitoring systems. There was visible damage to the monitoring systems within 2 years because of chemical exposure during the disinfection process. Such damage is susceptible to unreachable microbial reservoirs that inhibit disinfection, creating severe liability and costs for the hospital and manufacturer.

The Challenges and Gaps That Were Identified

The medical device company identified a lack of understanding and discussion about infection prevention products and guidelines used within the hospital. Although the medical device company met with many key decision makers, there was no central point of contact for them to work through, resulting in a breakdown of communication and the lack of involvement of critical experts during the evaluation process. Also, health care experts were excluded from initial meetings before the damage occurred; had they been consulted, it is possible some issues could have been avoided.

The case study also provided a clear example of the lack of guidelines and testing requirements for surface materials and products. When the medical device company applied for US Food and Drug Administration (FDA) 510(k) clearance, which is a process that evaluates a device’s safety against comparable legally marketed devices, they had testing done for surface disinfection and compatibility. The company was left to determine which cleaning agents to recommend for testing. Only 1 disinfectant was tested. The case study found that the hospital’s infection prevention and control guidelines did not support the use of the only disinfection method prescribed by the medical device manufacturer. The hospital was left to find an alternative for disinfection after purchasing the devices.

The fact that there are no guidelines or minimum testing requirements to validate surface disinfection compatibility is a problem. Minimum testing should require all categories of US Environmental Protection Agency (EPA)-registered hospital-grade disinfectants. There are hundreds of proprietary disinfectant products on the market in addition to no-touch technologies, and it would be cost prohibitive to test all disinfectants. However, by testing the categories of disinfectants, foundational information can be gained. Going beyond the minimum testing and working with the disinfectant companies from which hospitals purchase products will be essential.

Also discovered during this investigation were conflicting instructions for use (IFU) and care and maintenance manuals. The IFU provided information for the possible use of 2 other disinfectants. However, in small print was a warning against the use of the alternative disinfectant selected by the hospital, as there was concern that it may cause corrosion. Unfortunately, the small print was not noticed until the damage had occurred.

It was also determined that not all health care personnel were trained for cleaning and disinfection, such as their nursing staff disinfecting part of the device during patient care. They did not have access to the information they needed and were not offered the basic training.

Materials were not tested or evaluated for cleanability during the surface material selection process and before product development. It is currently not common for raw material manufacturers to test their materials for surface disinfection compatibility before selling them to manufacturers, which is missing a vital step. Product designers must have this information to support that the product’s design can be cleaned and disinfected without damage.

It was noted that medical suppliers benefit from having coordinated access to clinical staff for feedback on successes and potential device improvements. It is important to include critical information about the cleaning and disinfecting agents and processes used within the hospital. The information gained will support the manufacturer as they identify disinfectants for testing.

Before purchasing the monitoring device, the hospital’s evaluation and selection process would have benefited from active participation from a diverse group of health care professionals responsible for infection prevention, including environmental service, infection prevention, biomedical, nursing, and clinical professionals. All these professionals evaluate products differently, and the combined knowledge and discussion provides valuable insight into potential challenges and successes.

In the past 6 months, several medical device manufacturers faced FDA recalls for surface disinfectant incompatibility issues that caused risk to patients. Each of the recalls resulted in a requirement to do additional testing for surface disinfection compatibility and the rewriting of IFUs. Recalls are costly and could be avoided if guidelines and minimum testing recommendations were identified and followed.

Infection preventionists can help drive more awareness about surface disinfection compatibility. We can start with collaboration with health care personnel, biomed, raw material suppliers, device manufacturers and designers, and disinfectant manufacturers. We can bring together all the different groups working on surfaces to help health care facilities understand the importance of surface disinfection compatibility, surface disinfectant testing, IFUs, and how they are all tied together. We must work together to achieve the following:

Develop a minimum standard for surface disinfectant compatibility that tests categories of disinfectants instead of proprietary products.

 If categories of disinfectant chemistries are tested rather than specific brand names, this helps simplify and clarify IFUs. This allows health care facilities to determine whether the products they already use are compatible with their equipment and medical devices. HSI has developed minimum testing standards, using 7 categories of EPA-registered, hospital-grade disinfectants. By bringing this issue to the forefront and addressing the issue at a microbial level, we will begin to see sustainable solutions to mitigate the spread of HAIs.

Designate a single point of contact within a health care organization to facilitate collaboration between manufacturers and health care professionals and to communicate important matters to all parties.

 Health care facilities and systems have equipment and medical devices that are damaged or placed out of service for reasons not always known to staff. Having 1 “point person” to report equipment and device issues to, such as damage from cleaning products, would be invaluable.

Establish a greater understanding of real-life challenges health care professionals face when working to mitigate the spread of infections within the health care setting. 

Medical device designers and manufacturers and disinfectant manufacturers do their best to create products that help keep patients and staff safe. However, sometimes there is a disconnect between the users and the vision research and development had in mind. A product with multiple nooks and crannies—although helpful in the design and build of a device—can pose a nightmare for cleaning and disinfection.

­­­­Build awareness around the selection of surface materials during the design phase by medical device manufacturers based on surface disinfection compatibility.

 Raw materials must meet minimum standard requirements. The number of different types of medical devices and equipment is overwhelming. When you consider all the possible surface material components, such as plastics, metals, and coatings, it’s not hard to see how easily surface disinfection incompatibility can happen.

Create guidelines for product reviews before purchase, as well as checklists for health care selection teams within the health care setting that provide essential information for product value analysis professionals.

 Infection preventionists already have guidelines or checklists to help evaluate disinfectants. They also need tools for assessing surface disinfection compatibility to determine whether a surface material or product can be safely cleaned and disinfected without causing damage that can harbor and transmit dangerous pathogens.

Medical device suppliers should provide maintenance training, including a review of cleaning and disinfection for all users of their equipment or devices.

The lack of attention paid to surface disinfection compatibility with patient care equipment and devices results in damage, failure, and recalls of expensive—and sometimes critical—patient care equipment. Addressing the issue of surface disinfection compatibility can help prevent these financial losses. However, understanding how critical the issue of surface disinfection compatibility is to protect patients and keep health care personnel safe when handling patient care equipment and devices is more important. Infection preventionists can help drive the change needed to address surface disinfection compatibility in health care.

Zheng S, Bawazir M, Dhall A, et al. Implication of surface properties, bacterial motility, and hydrodynamic conditions on bacterial surface sensing and their initial adhesion. 

. 2021;9:643722. doi:10.3389/fbioe.2021.643722

Surface disinfection incompatibility with medical devices creates potential patient risks. Healthcare Surfaces Institute. September 2021. Accessed March 11, 2022. https://www.healthcaresurfacesinstitute.org/case-studies/surface-disinfection-incompatibility-with-medical-devices-creates-potential-patient-risks/

The surface material and product damage caused by new advances in disinfection technology must be addressed for patient safety.

Surface Disinfection Incompatibility Does Not Support Effective Cleaning and Disinfection

In the 15th century, Niccolò Machiavelli, a politician who is famous for his canny strategic advice, wrote, “There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success than to take the lead in the introduction of a new order of things.”

This is still true. Say you’re trying to get a hand hygiene intervention tested in your hospital. You know there’s a clear need. You have historical and current data about infection incidence, you have anecdotal evidence from staff and patients, and you’ve seen with your own eyes how often the guidelines are breached. However, the people running the place don’t see it the same way, which is the problem you’d like to solve. What do you do?

Study after study of infection prevention and control (IPC) interventions and programs have concluded that you don’t get far without management support. Such support can take many forms, including funding for the project, communication about the project, and visible backing for the project. There is no question that to execute a project successfully, a team must be well rounded, with representation ideally from all stakeholders. That includes leadership.

It’s usually easy to find out where and why management support might be needed. Just ask the staff. For example, a Cochrane review observed 20 studies exploring the views of health care workers (HCWs) on adherence with IPC guidelines for respiratory infectious diseases.

 The HCWs said they weren’t sure whether to follow local guidelines if those differed from national guidance. They struggled to follow long or unclear guidelines, especially if the advice kept changing. In fact, nurses in one study termed impractical guidance as 

. They pointed to a lack of training about infection and how to use personal protective equipment.

One of the top findings was that adherence was influenced by the level of support HCWs felt they received from their management team. HCWs who perceived that hospital administration and managers were supportive and who openly demonstrated that support were more willing to engage with IPC. For example, one nurse was quoted, saying “The practice by administrators of making rounds on the units and offering words of encouragement was perceived as being supportive of staff.”

Other investigators who reviewed 56 papers on HCWs’ adherence with infection control (IC) measures found that leading by example was key—not just setting standards for IC practices but reinforcing them.

Communication, verbal and nonverbal, is perhaps the most important variable when you need to get parties of any kind to go along with something. “When I’ve encountered barriers along the way of opposition, it usually ends up being a case of miscommunication or misunderstanding. That is why communication with all impacted stakeholders is so important at the beginning,” Rebecca Leach, MPH, BSN, RN, CIC, told 

Leach, who is the director of infection prevention at a level 1 trauma center in Phoenix, Arizona, has experience in both trying to implement infection prevention (IP) practices and getting support from leadership to invest resources to build the IP program. “Implementing change brings about anxiety, which is a natural response,” she said. “It’s easy to get frustrated with a person or group who seems resistant. However, we have to be a bit of a psychologist and try to understand what the underlying fears are associated with the proposed change.”

It can also help to consider managerial style. Managerial styles reflect how the best managers “will achieve strategic goals through task assignment and resources allocation, and how they will use management information for controlling and monitoring the achievement of different strategic policies,” according to David Naranjo-Gil, of the Universidad Pablo de Olavide in Sevilla, Spain.

 For instance, the style might be proactive or interactive, focusing on solving problems before they have a chance to appear. Or it might be reactive or diagnostic, focused on responding to events after they have appeared.

“A proactive managerial style involves debate and dialogue among managers and subordinates at different organizational levels, which stimulates opportunity-seeking, proactive behaviors and encourages the development of new activities and actions. In contrast, a reactive or diagnostic managerial style focuses on controlling efficiency of prescribed tasks and on monitoring organizational outputs by comparison with preset standards to analyze potential deviations and correct them to achieve the intended strategic goals,” Naranjo-Gil wrote.

If you want to introduce a project, you need leadership to agree. But it isn’t enough to get a “go ahead”—you need commitment. “Countless quality and safety initiatives are launched with good intent but wither on the vine because of a lack of effective leadership,” said investigators from the Vanderbilt University Medical Center (VUMC) in Nashville, Tennessee.

They launched a system-wide initiative aimed at achieving and sustaining hand hygiene (HH) adherence and reported on the implementation and impact. Based on their experience, they recommend that project leaders continuously evaluate health system leadership support. Some questions they found critical to evaluating commitment include the following:

Is the project consistent with the system’s quality and safety priorities?

Does financial support exist, including support for key personnel?

Are system leaders willing to publicly affirm commitment to the goal and its associated metrics?

Are leaders willing to address nonadherent individuals?

“Too often, system leadership support is signaled initially but then disappears once difficult decisions arise, undercutting the authority of the project team,” the investigators said. To forestall that, before beginning the VUMC HH program, they secured leadership commitment. When individuals resisted elements of the HH plan, VUMC leadership was prepared and responded “in a measured and effective way.”

Of course, even with willing participants on all sides, it’s not uncommon to run into obstacles, such as a promising avenue getting blocked or support suddenly disintegrating. You find that Option A doesn’t work against Obstacle A, so you try Option B, then come up against Obstacle C. “This is typically where I apply the PDSA [Plan-Do-Study-Act] cycle,” Leach said. The PDSA cycle is a process for testing, evaluating, and improving a project or product.

“With every new initiative or proposal to leadership, I do my best to anticipate the barriers, pull together key stakeholders ahead of time to get more information, and try to have a plan in place before things are implemented,” Leach said. “Of course, you will always have something come up or a plan that doesn’t work. One thing is not to take it personally, because we are working with humans, and you cannot control all the variables. Keeping flexibility, keeping your stakeholders engaged, and being open to changing the course to address new barriers is important.”

Some obstacles are recurrent. In fact, they might be said to be endemic. “Financial barriers are never a surprise, because typically, IP departments do not have budgets beyond personnel, so it is never our money being used for new products or to help implement change,” Leach said. The most common obstacle “tends to be competing priorities,” she said. “There are always several quality and safety initiatives going on at the same time, as well as other organizational challenges, such as staffing.” 

When Leach runs into that kind of recurrent issue, her practice is “to try to meet the team where they are, listen to what they perceive as barriers, and figure out how to integrate HAI [health care–acquired infection] prevention into everyday practices. Also by building trust and relationships and telling stories. Telling staff stories about patients they’ve cared for can be very impactful.” Basically, she gives a case summary about the patient, including what happened to them, where they went, and what their state upon discharge was.

What if the issue is not just about getting interventions or projects approved but about justifying the need for your entire department? “A few years ago, our [IPC] department was on the chopping block to reduce its size. We were 8 IPs covering a 900-bed acute care academic medical center with 5 other hospitals in our system,” one IP told 

®. The IP team was more than surprised. “The need to justify the existence of our department rocked our world.”

The main obstacle was the fact that IP was not a revenue generator. “The ‘powers that be’ were looking for ways to save money,” the IP said. “Fortunately, our medical director was determined to keep the staff and department. She began building a case based on patient safety—the main reason [IPC] exists—by outlining costs of HAIs. We listed everything IC laid hands on. We provided our medical director with a list of all the areas we covered, all the education we provided, all the surveillance we performed, all the construction projects we provided support to, [and] how closely we worked with risk and quality assurance, just to give a few examples. She was able to figure out how much money we saved the hospital by doing all the things we did.”

One of the more challenging tasks was “helping nonclinical decision makers understand all that infection prevention does,” the IP said. The main takeaway from the experience was that “everything comes down to money. If you can prove that your department—although not a revenue generator—saves the facility money, that’s a good start. Also be able to list [what] your department is involved in. That was a real eye-opener to the C-suite,” the IP said.

What’s the hardest part of getting buy-in? “Right now, the hardest part is that everyone is tired,” Leach said. “COVID-19 response has exhausted staff and leadership. [Although] many are eager to work on something other than COVID-19 response, we [must] acknowledge that there will be long-lasting impacts to the morale and mental health of HCWs. Similarly, we’ve had so much movement of staff, with people leaving, new graduates, travel staff, etc, [that there are now] so many new faces to educate...and try to bring into the fold.”

With so many variables to consider, including an overwhelming pandemic, there is always a potential for setbacks. Goals will change, great ideas will fall by the wayside, and you may need to pause and regroup again and again. But as the Taoist Sun Tzu teaches in 

, choose your battles. “He will win who knows when to fight and when not to fight,” Sun Tzu wrote. Over 2000 years later, this is still a useful concept.

“Sometimes you will not be able to overcome a barrier, and then you try to compromise,” Leach said. “I pick my battles and make sure my perspective is adjusted and that it’s not just me pushing something because I think it’s the best way to handle the situation.” It can be a bitter pill to swallow, but sometimes you have to let go. You can’t win them all.

Houghton C, Meskell P, Delaney H, et al. Barriers and facilitators to healthcare workers’ adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis. 

. 2020;4(4):CD013582. doi:10.1002/14651858.CD013582

Brooks SK, Greenberg N, Wessely S, Rubin GJ. Factors affecting healthcare workers’ compliance with social and behavioural infection control measures during emerging infectious disease outbreaks: rapid evidence review. 

. 2021;11(8):e049857. doi:10.1136/bmjopen-2021-049857

Naranjo-Gil D. Accomplishing water strategy policies in hospitals: the role of management information systems and managerial styles. 

Talbot TR, Johnson JG, Fergus C, et al. Sustained improvement in hand hygiene adherence: utilizing shared accountability and financial incentives. 

. 2013;34(11):1129-1136. doi:10.1086/673445

Health care workers' adherence to guidelines and overall job satisfaction are influenced by the level of support they feel they receive from their management team. 

Getting Managerial Buy-In for Infection Control Efforts 

Infection control became a prevalent science in the late 1950s, focused on addressing nosocomial staphylococcal infections. By 1999, the focus on infection control began to transform to infection prevention, no longer accepting health care–acquired infections (HAIs) as an unpreventable cost of business. Instead, the focus shifted to the rapid identification of infections, taking timely action to analyze them, and actively participating in the care processes.

Sixty percent of surgical site infections (SSIs) were estimated to be preventable, using evidence-based measures that have influenced pay-for-performance and quality-improvement goal metrics, according to a study by Ban et al.

 Addressing strategies for the prevention of SSI can include all avenues of patient care and involve all actual and potential participants in the care continuum, from patients and families in the pre- and posthospital settings to hospital and facility administrators to physicians and nurses to laboratory and supply chains to quality and risk management departments. The care continuum does not stop or start at the hospital doors; indeed, it should start in a patient’s home and continue through a hospitalization to the outpatient care centers and back home or to a care facility.

Gwen Borlaug, MPH, CIC, FAPIC, infection prevention epidemiologist and former director of the Wisconsin Division of Public Health’s Healthcare-Associated Infection Prevention Program, notes that surveillance and performance improvement and implementation science are 2 areas infection preventionists (IPs) can provide that support prevention of SSI. Effective prevention of SSIs is based on active surveillance by IPs, then the findings are communicated back to staff and providers, and they use opportunities for education to improve protocols and compliance.

 Anderson et al notes that IPs must have training in SSI surveillance, have knowledge of and the ability to prospectively apply Centers for Disease Control and Prevention (CDC) and National Healthcare Safety Network definitions for SSIs, and be able to provide feedback and education to health care personnel.

SSI Statistics, Risk Factors, and Interventions

A 2016 update from the American College of Surgeons and Surgical Infection Society found that SSIs accounted for 20% of all HAIs.

 An infection incidence of 2% to 5% of patients undergoing an inpatient surgery means an estimated annual 160,000 to 300,000 patients in the United States acquire SSIs yearly.

 SSIs increased the length of inpatient hospital stays and potential mortality 2- to 11-fold (77%) primarily because of the infection.

 Patient care costs were not only related to extended inpatient stays but also emergency department visits and a reported 90,000 annual readmissions.

The CDC classified SSIs by depth and which tissue spaces were involved. According to the CDC, a superficial incision involves only the skin or subcutaneous tissue, whereas a deep incisional SSI involves the deeper fascia or muscular layers. SSIs can also affect organ spaces of any part of the body opened or manipulated during the procedure.

and extrinsic components. Intrinsic factors include patient-related modifiable and nonmodifiable factors.

Modifiable factors can include the following:

preoperative albumin less than 3.5 mg/dL,

Nonmodifiable patient factors can include the following:

history of skin or soft tissue infections.

Extrinsic factors include procedure-and facility-related factors.

Procedural risk factors can include emergency procedures, increasing complexity, and higher wound classification. Procedural risk factors can also be attributed to preoperative, intraoperative, and postoperative factors.

Preoperative risk factors can include the following:

Intraoperative risk factors can include the following:

With 60% of surgical site infections estimated to be preventable, IPs hold a key prevention role in patient safety. 

Infection Control Today, May 2022, (Vol. 26, No. 4)

Environmental Measures Disrupt Transmission of HAIs

Surface Disinfection Incompatibility Does Not Support Effective Cleaning and Disinfection

Getting Managerial Buy-In for Infection Control Efforts

The Role Infection Preventionists Play in Thwarting Surgical Site Infections

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C diff Rates Reduced Nearly 75% With Hydrogen Peroxide Disinfection System

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