A new infection control model highlights 5 key moments for disinfecting high-touch surfaces in patient care, aiming to reduce health care–associated infections and improve patient safety.

Beyond Hand Hygiene: The Five Critical Moments for Environmental Disinfection in Health Care

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Infection prevention has long focused on hand hygiene, but what about the surfaces patients and health care workers touch throughout the day? Jim Gauthier, MLT, CIC, alongside coauthors Carol Calabrese, BS, RN, CIC, and Peter Teska, MBA, introduced the concept of 

Targeted Moments of Environmental Disinfection (TMED)

—a structured approach identifying 5 critical moments for cleaning high-touch surfaces in patient care areas, published in 

The Joint Commission Journal on Quality and Patient Safety.

), Gauthier discusses the importance of real-time disinfection, the hidden dangers of overlooked surfaces, and practical strategies to integrate TMED into daily health care practices, aiming to reduce health care–associated infections and enhance patient safety.

“TMED is a heuristic, risk-based model proposing additional cleaning and disinfecting within the patient zone modeled on a similar concept developed by WHO [World Health Organization] for hand hygiene,” the authors wrote. “TMED identifies and suggests when disinfection should be conducted by [health care workers], either after or before certain procedures or events that may leave organisms on high-touch surfaces, or to remove organisms that may have been deposited during other care procedures.”

: Please explain to me what your commentary covered.

What [the commentary] boils down to is that we told health care workers back in the 2000s when to wash or sanitize their hands, and WHO published the 5 Moments for Hand Hygiene [guidance],

 which boils down to these are 5 critical moments [when] we need you to make sure your hands are clean: before you have contact with the patient, before you do anything very, very clean or aseptic, after contact with blood or body fluids, before you leave the patient’s room, if you’ve touched the patient’s environment.

When I look at cleaning and disinfection, we go into the patient’s room, hopefully once a day, clean high-touch surfaces, and that’s about it. [Environmental services (EVS) goes] in and [cleans] well once a day, and then care occurs for the other 23.5 to 23.75 hours of that day with no other targeted cleaning being done based on the care we did. So that’s where the genesis of this commentary came from.

The point of the paper is care happens all day. There is not an EVS [technician] standing behind the door every time somebody comes in the door to perform some form of care for the patient or the resident, if we’re talking long-term care. As I put the paper together with my peers, and as I’ve talked about it to different infection control groups and to [EVS] groups, I always get this feedback of, well, what do you think we should clean and what’s not in the article, and I should probably do a follow-up to it. But what it boils down to is if, during care, you’ve touched it or used it, clean. But we [broke it down] into 5 moments.

As a microbiology technologist, I understand the movement of microorganisms. I know what they look like, what they smell like, and where they can hide. When [my coauthors and I] start looking at papers that are trying to figure out an outbreak and where these organisms came from, the 2 dirtiest surfaces in the hospital, when I looked at the papers, were the over-bed table and the bed rails. When I started looking at what you can find on the over-bed table and the bed rails, we thought, “Well, those are also high-touch surfaces. They get touched a lot, and we probably need to clean those more than just once a day.”

: What are the 5 moments you are recommending?

What we’re suggesting is disinfecting the over-bed table.

 Before placing food or drink on the over-bed table, it must be disinfected.

 Before and after aseptic practices. For instance, if health care workers come in to change a dressing, insert a line, or perform catheter care, they need to disinfect before establishing a clean space and disinfect after.

 Involves anything related to feces or respiratory secretions within the patient’s bed space. For example, if the patient is expectorating for you, they’re coughing up something. If you need to assist a patient with their incontinence products and help them into a clean product, you’ll need to disinfect something when you’re done.

 After any patient bath within the patient bed space, if you give the patient a basin and a washcloth and say, “Here, clean yourself up. Breakfast is on its way,” you’re likely going to need to disinfect afterward. If you’re using the prewetted wipes that are quite common in health care today, you can warm a small package of wipes, wipe the patient down, or allow [them] to clean themselves; you have 1 wipe for each part of the body. In my experience, they often end up on the over-bed table. So again, after any patient bathing, you need to disinfect something.

 Does anything used on or used by a patient that touches the floor need to be disinfected? We all have experiences where somebody will come into a room and see the cell phone charger on the floor, pick it up, and hand it back to the patient. That will fall, hit the floor, and return to the patient without being disinfected.

As these moments arose, much of this came from reading the literature and addressing issues, whether through outbreaks or discussing topics such as what we should do with floors. It doesn’t matter too much what you do with a floor; if anything touches the floor, which will be used by or on a patient, it is infected when it hits the floor. [Our] paper has 51 references as commentary to support each of these points.

The over-bed table that the patient eats off—none of us eat in our restrooms, I hope, at home or in our bathrooms. Well, people probably do. But patients are somewhat trapped there, so they might use a urinal if they’re bedridden and place it on the over-bed table if they don’t use the one on the side. All of us can recall what we’ve seen on over-bed tables if we’ve been in health care. That’s where I found evidence of bacteria, and I suggested that we disinfect that over-bed table before placing anything on it. The same applies to all the other moments mentioned in the paper. One of the main pieces of feedback we receive is, “Don’t give me anything else to do.” Especially for registered nurses trying to care for too many patients, don’t add more tasks to their load.

We designed a little table [with] the 5 moments across the top and looked at different kinds of patients. A ventilated patient in the intensive care unit is going to require a lot more wiping if someone tries to follow these 5 moments than a medical-surgical patient who is able to ambulate, look after themselves, use the toilet. You may only be using 3 or 4 wipes just because they eat in bed, so it’s not as onerous as what we were looking at. 

We also realized that for this concept to work, the health care provider doing the care can’t take the time to look for a wipe because there are disinfectant wipes that you don’t want near the patient. They’re either caustic or they are poisonous. You don’t want to leave them near a patient. So the staff know where they are, but if they’re not right at the bedside, you’re going to have this issue of staff not completing the 5 moments.

We learned this with hand hygiene, and we developed something called point of care [for] hand hygiene products, where the point of care is the patient and the care provider and the care all meeting together, and you want the hand sanitizer so that the care provider only has to reach out the hand sanitizers there. They can sanitize their hand per moment 2 before they move on to another moment.

We propose in the paper that you need to have a safe disinfectant wipe that can be kept where the care will occur. You need to look at the safety data sheet around the wipe to find a wipe that works quickly so that surfaces aren’t wet around the patient for 3 to 5 minutes. Find a product that doesn’t require personal protective equipment to touch it. Staff always use their gloves because of the care that they provide and other things like that. But if you can find a safe-enough product that’s [kept at the] head of bed, you may also have the visitors or family helping to keep the environment cleaner around the patient. There will take some education because we run into the problem of people flushing wipes—not only family, but we’ve got care providers who, if they have a wipe that is grossly soiled with feces, they may go and flush it, and that causes problems down the road. But with a bit of education, I don’t see this as a huge problem.

Gauthier J, Calabrese C, Teska P. Targeted Moments of Environmental Disinfection. 

 2020;46(3):167-172. doi:10.1016/j.jcjq.2019.11.009

Five moments for hand hygiene. World Health Organization. Accessed February 4, 2025. 

https://www.who.int/publications/m/item/five-moments-for-hand-hygiene

Videos

A group of experts highlight their infection control model, which highlights 5 key moments for disinfecting high-touch surfaces in patient care, aiming to reduce health care–associated infections and improve patient safety.

Beyond Hand Hygiene: The 5 Critical Moments for Environmental Disinfection in Health Care

Imagine a patient undergoing what should be a routine surgery. The instruments used have been carefully sterilized, but lurking on their surfaces are microscopic endotoxins—heat-resistant and undetectable by standard sterilization methods—posing a hidden threat to patient safety. The instruments used have been sterilized, and the procedure goes smoothly, but days later, the patient develops a severe, unexplained infection. 

The culprit? Invisible, heat-resistant endotoxins lurking on supposedly sterile medical devices. These silent saboteurs pose a grave threat to patient safety, capable of triggering fevers, multiorgan failure, and even fatal septic shock. Despite rigorous sterilization protocols, endotoxins persist in health care settings, demanding strict regulatory oversight and innovative mitigation strategies. Understanding the nature of endotoxins and their impact on sterilization practices is crucial in ensuring patient safety and preventing deadly infections.

Endotoxin lipopolysaccharides (LPSs) trigger a vast spectrum of biological responses, both harmful and beneficial to the host organism.

 They are commonly found in the environment, particularly in the gastrointestinal tract, and are the most significant pyrogens in drugs and medical devices. Endotoxins can be transmitted through medical equipment, intravenous medications, saline solutions, implants, and sterile water.

LPS, present in the outer membrane of gram-negative bacteria, is heat-stable and released upon bacterial lysis or death.

 LPSs are crucial to bacterial organization and stability.

 Structurally, endotoxins consist of 3 regions: O-specific antigen, core polysaccharide, and lipid A. These components are responsible for toxic effects, including fever, multiorgan failure, sepsis, and septic shock.

 Although the O antigen is the outermost part and nontoxic, the core polysaccharide varies among bacterial strains.

 The lipid A portion is highly toxic and anchors the endotoxin to the bacterial membrane.

 Although endotoxin structure is largely conserved, it can undergo modifications in response to environmental changes.

In the early 1800s, researchers speculated that microscopic organisms could be transmitted through soil and air. Louis Pasteur later demonstrated the role of microbes in infectious diseases.

1809-1822: Sir John Burdon-Sanderson confirmed von Haller’s findings, proving that putrid fluids caused animal fever and disease.

1822: François Magendie linked putrid water conditions to severe illnesses such as typhoid fever and cholera.7

1856: Peter L. Panum observed that injections of putrid fluid induced fever.

 Later in 1856, Panum demonstrated that the fever-inducing substances derived from putrid matter were heat-stable and water-soluble.

1880: Julius Wagner-Jauregg experimented with inducing fevers using endotoxins, later earning a Nobel Prize for his research on artificial fever induction.

1884: Hans Christian Gram developed the Gram staining technique.

1890s: Eugenio Centanni successfully isolated endotoxins from bacterial lysates, confirming their heat stability.

1892: Richard Pfeiffer distinguished between heat-labile exotoxins and heat-resistant endotoxins and coined the term endotoxin.

Although endotoxin injections evoke memories of unethical research practices, gram-negative bacterial endotoxins have been used in medical treatments for more than a century. Initially, they were used to induce fever to treat infections such as arthritis, eye inflammation, and cancer.

By the 1940s, researchers sought to understand endotoxin tolerance through controlled administration.

Findings from studies revealed that humans are highly sensitive to endotoxin effects.

 Today, purified LPS is a critical tool in immunology research, helping to develop better treatments for septicemia.

The US Food and Drug Administration (FDA) identifies multiple sources of endotoxin contamination, including solvent water, sterilization water, packaging materials, and manufacturing equipment.

 Contamination can occur at any point in the reprocessing cycle, including cleaning, sterilization, and storage, making consistent monitoring essential.

 Medical equipment, including surgical instruments, catheters, and implantable devices, can become contaminated when exposed to water sources that contain endotoxins, potentially resulting in patient exposure.

Once endotoxins enter the bloodstream (endotoxemia), they trigger severe inflammatory responses. The immune system recognizes endotoxins as foreign threats, activating a powerful immune reaction that can cause fever, diarrhea, and, in extreme cases, septic shock.

Endotoxins contribute to bacterial infections such as typhoid fever, tularemia, and the plague. They also play a significant role in hospital-associated infections caused by gram-negative bacteria, including Escherichia coli, Proteus, Pseudomonas aeruginosa, Enterobacter, Serratia, and Klebsiella.

Despite extensive research, the exact role of circulating endotoxins in septic shock remains debated. LPSs function as alarm molecules in the innate immune system, signaling potential bacterial invasions. Although small amounts of LPS help the immune system fight infections by coordinating antimicrobial responses, large-scale endotoxin release can overwhelm the body, leading to widespread inflammation, tissue damage, organ failure, and, in severe cases, death.

Endotoxins persist on sterile biomedical devices because sterilization processes deactivate microorganisms rather than eliminate them entirely. Highly heat-resistant endotoxins can survive regular sterilization methods because most standard techniques, such as steam and chemical sterilization, effectively kill bacteria but do not eliminate the heat-stable endotoxin molecules they release. This resilience necessitates specialized
decontamination strategies to prevent patient exposure. The only proven method to destroy them is dry heat at 250 °C for 30 minutes or 180 °C for 3 hours, which is not feasible for many polymeric and metallic medical devices.

 As a result, endotoxins may remain on surgical instruments and implants, posing infection risks to patients.

The FDA has implemented essential regulations about restricting endotoxins in medical devices. These regulations have significant implications for medical device manufacturers, as they depend on the device’s intended application and interaction with bodily surfaces, cavities, and fluids.

 In sterile processing, screw caddies and implant plates undergo multiple rounds of cleaning and sterilization before being used on a patient. Some sizes may not be used for years.

The American National Standards Institute (ANSI)/Association for the Advancement of Medical Instrumentation (AAMI) ST108 standard provides a regulatory framework for water quality in sterile processing, ensuring that endotoxin contamination is minimized.

 This standard categorizes water into utility water, critical water, and steam, with strict contamination thresholds. Poor water quality can result in device malfunctions, toxic residue on implants, patient infections, and pyrogenic reactions.

To comply with ANSI/AAMI ST108, sterile processing departments must implement robust water purification strategies, including reverse osmosis, deionization, UV disinfection, and ultrafiltration. Monthly endotoxin testing is recommended for all reprocessing areas, including steam, ultrasonic, mechanical washers, and final rinse water.

 Additionally, in-line infection control filtration is crucial for removing endotoxins that sterilization alone cannot eliminate. Compliance with ANSI/AAMI ST108 is critical in preventing endotoxin-related infections and ensuring patient safety by addressing water quality at every stage of the reprocessing cycle.

Endotoxins pose a significant risk to patient safety, particularly in medical device sterilization. Although extensive research has improved our understanding of endotoxin mechanisms, challenges remain in eliminating them from health care environments. Advancements in detection and decontamination methods are crucial in minimizing endotoxin-related infections. 

By complying with strict regulations such as ANSI/AAMI ST108 and improving sterilization protocols, sterile processing departments can mitigate the risks associated with endotoxin contamination, ultimately enhancing patient outcomes. Future research into advanced filtration technologies, improved endotoxin detection methods, and novel sterilization techniques will be essential in further reducing endotoxin-related risks in health care settings. 

Galanos C, Freudenberg MA, Matsuura M. Mechanisms of the lethal action of endotoxin and endotoxin hypersensitivity. In: Friedman H, Klein TW, Nakano M, Nowotny A, eds. 

The Biomaterials: Silver Jubilee Compendium.

 Accessed February 3, 2025. https://www.merriam-webster.com/dictionary/endotoxin

Ongkudon CM, Chew JH, Liu B, Danquah MK. Chromatographic removal of endotoxins: a bioprocess engineer’s perspective. 

Das AP, Kumar PS, Swain S. Recent advances in biosensor-based endotoxin detection. 

 2014;51:62-75. doi:10.1016/j.bios.2013.07.020

 March 24, 2022. Accessed February 3, 2025. https://www.bmglabtech.com/en/blog/what-are-endotoxins/

History of LPS research. FUJIFILM Wako Chemicals. August 3, 2020. Accessed February 3, 2025. https://www.wakopyrostar.com/blog/kit-lal/post/history-of-lps-research/

Bahador M, Cross AS. From therapy to experimental model: a hundred years of endotoxin administration to human subjects. 

 2007;13(5):251-279. doi:10.1177/0968051907085986

Min H. The history and evolution of endotoxin testing. 

 January 22, 2025. Accessed February 3, 2025. https://www.rapidmicrobiology.com/news/a-q-a-on-usp-recombinant-innovation-and-future-trends

The impact of endotoxin on the human body. FUJIFILM Wako Chemicals. July 29, 2024. Accessed February 3, 2025. https://www.wakopyrostar.com/blog/post/the-impact-of-endotoxin-on-the-human-body/

Mims’ Pathogenesis of Infectious Disease.

Opal SM. Endotoxins and other sepsis triggers. 

Silhavy TJ, Kahne D. Overview of the bacterial envelope. In: 

Bacterial Endotoxins: Structure, Function, and Role in Disease.

Goveia VR, Mendoza IYQ, Guimarães GL, et al. Endotoxins in surgical instruments of hip arthroplasty. 

 2016;50(3):405-410. doi:10.1590/S0080-623420160000400005

ANSI/AAMI ST108: its impact on sterile processing. 

 November 18, 2024. Accessed February 3, 2025. https://www.nephros.com/blog/ansi-aami-st108-its-impact-on-sterile-processing/

Articles

Invisible yet deadly, endotoxins evade traditional sterilization methods, posing significant risks during routine surgeries. Understanding and addressing their threat is critical for patient safety.

Silent Saboteurs: Managing Endotoxins for Sepsis-Free Sterilization

Effective environmental services (EVS) are critical in maintaining a safe and healthy health care environment. Properly trained housekeeping staff are essential in preventing health care–associated infections (HAIs), ensuring compliance with regulations, and promoting patient and staff safety. Moreover, EVS leaders must possess supervisory skills and advanced knowledge of cleaning protocols to ensure high hygiene standards. This article delves into the importance of training housekeeping staff and leaders in health care facilities, highlighting key reasons and evidence-based practices to support this imperative.

HAIs are a significant challenge in health care settings, affecting approximately 1 in 31 hospital patients on any given day in the US.

 Contaminated surfaces, equipment, and high-touch areas contribute to transmitting pathogens such as methicillin-resistant 

. Proper training equips housekeeping staff with the skills to clean and disinfect effectively, reducing microbial loads on surfaces and minimizing infection risks.

Key aspects of training should include the following:

 Housekeeping staff should learn how pathogens spread and which surfaces are most likely to harbor infectious agents. This includes understanding the role of high-touch areas, such as doorknobs, light switches, and handrails, in transmitting bacteria and viruses. Recognizing these hot spots helps prioritize cleaning efforts and reduce the risk of infections spreading within the facility.

 Training should emphasize the appropriate selection, dilution, and application of disinfectants, ensuring compliance with manufacturers’ guidelines. Misusing cleaning agents, such as overdiluting or mixing incompatible products, can reduce their effectiveness and cause harm. Staff should be trained to identify the correct cleaning agent for each surface and follow best practices for safe and effective use.

 Staff must understand how to use personal protective equipment (PPE) to protect themselves and prevent cross-contamination properly. This includes selecting the appropriate PPE, such as gloves, masks, and gowns, for the task at hand and knowing how to don, doff, and dispose of it safely. Proper PPE usage minimizes exposure to harmful pathogens and ensures a safer environment for staff and facility occupants.

Evidence suggests that enhanced cleaning protocols and staff education significantly reduce the incidence of HAIs. For example, findings from a study by Kundrapu et al from 2012 demonstrated that cleaning techniques can reduce 

 contamination in health care environments by more than 85%.

Inadequate cleaning and disinfection can lead to unsafe environments, putting patients, staff, and visitors at risk. Training ensures that EVS staff are well-versed in the following:

 Critical zones such as operating rooms, intensive care units, and isolation rooms require specialized cleaning protocols.

 Proper medical waste disposal prevents exposure to biohazards and sharp objects, reducing injury and infection risks.

 Training on safe mopping techniques and floor signage reduces the likelihood of accidents.

Effective training prevents accidents and infections and fosters a culture of accountability and professionalism. Well-trained housekeeping staff can promptly identify and address potential hazards, contributing to a safer health care environment.

Health care facilities must comply with stringent regulations set by organizations such as the CDC, the Occupational Safety and Health Administration (OSHA), and The Joint Commission. Noncompliance can result in penalties, legal liabilities, and loss of accreditation.

Key areas of compliance include the following:

Implement evidence-based protocols for hand hygiene and use PPE.

Ensure the meticulous maintenance of comprehensive records about sanitation schedules, procedural protocols, and incident documentation essential for compliance and quality assurance in health care settings.

Implement comprehensive training programs for personnel to effectively prepare for and respond to evaluations conducted by regulatory agencies.

EVS leaders play a pivotal role in ensuring the effectiveness of EVS teams. Properly trained leaders provide effective oversight, motivation, and guidance to their teams, fostering a culture of excellence. Research by Hashim Zaman and Karim Lakhani from Harvard Business School in Boston, Massachusetts, found that managers sometimes sabotage talented employees to protect their own job security. Troubling results from a survey in this exploration revealed that 71% of executives had observed instances of top-down sabotage during their careers. Notably, 5% of the same respondents acknowledged engaging in actions that undermined their direct reports at some point in their professional tenure.

It is wise to determine what information to share when providing valuable insights to subordinates or selecting new leaders for the team. To paraphrase the biblical saying, avoid giving what is sacred to those who will not appreciate it or sharing treasures with those who may disregard or misuse them, potentially causing harm in return (Matthew 7:6). This exhortation, however, should not be misconstrued as an implication that subordinates or others are inherently unworthy of receiving critical information for professional growth. Instead, it underscores the principle that empowering individuals who lack the requisite values or competence may hinder the achievement of desired outcomes, irrespective of the quality of the information imparted. This also applies to appointing the wrong leaders to positions of authority, which can stifle growth and harm the organization’s vitality.

It is imperative to advocate for leadership that prioritizes transparency, fosters professional development, and embraces the recruitment of skilled talent. Key competencies for EVS leaders include the following:

 Effective leaders must know how to delegate tasks, resolve conflicts, and evaluate performance. Leadership training enhances their ability to motivate staff and ensure accountability. The lack of leadership skills is detrimental to the team and undermines the quality of patient care, inhibiting team members’ continuous learning and development.

 A comprehensive understanding of cleaning chemistries and industry standards is essential for effectively engaging with subordinates and sales representatives.

 To maintain high standards, it is essential to stay updated on emerging pathogens, cleaning technologies, and regulatory changes. Certifications from esteemed agencies that assess and enhance competencies are instrumental in equipping leaders and their teams to perform their responsibilities reliably.

For instance, findings from a study by Carling et al from 2008 highlighted that supervisory programs focusing on cleaning efficacy significantly improved surface disinfection, reducing HAIs.

Investing in housekeeping training yields substantial economic benefits for health care facilities. HAIs result in significant costs, averaging $25,000 to $40,000 per infection in direct medical expenses.

 Effective training reduces these costs by preventing infections and minimizing hospital readmissions. Moreover, trained staff improve operational efficiency, reducing turnover rates and the need for corrective actions.

Following are specialized trainings in cleaning and disinfection protocols as well as infection prevention and control practices available from several organizations:

Certified Health Care Environmental Services Professional (CHESP)

Offered by the American Hospital Association

Focuses on infection control, cleaning protocols, waste management, and patient safety

Certificate of Mastery in Infection Prevention (CMIP)

Offered by the Association for the Health Care Environment

Covers health care–specific cleaning practices, disinfection, epidemiology, microbiology, and regulatory issues

Offers courses in workplace safety, blood-borne pathogens, and hazard communication

Cleaning Industry Management Standard (CIMS)

Offered by the International Sanitary Supply Association

Focuses on management standards for cleaning applicable to health care facilities

Infection prevention and control training

Offered by organizations such as the CDC or the World Health Organization

Focuses on hygiene practices, infection control, and disinfection protocols specific to hospitals

Developing a robust training program involves the following:

 New employees should receive comprehensive training on cleaning protocols, safety procedures, and organizational policies.

 Regular competency assessments keep staff updated on best practices.

 Training should address specific needs, such as handling biohazards or cleaning isolation rooms.

 Encouraging feedback from staff helps identify gaps in training and opportunities for improvement.

Properly training housekeeping staff and ESV leaders is vital for maintaining a safe, compliant, and efficient health care environment. Training reduces the risk of HAIs, enhances safety, ensures regulatory compliance, and fosters a culture of excellence. Health care organizations must prioritize comprehensive training programs and continuous education to achieve these goals. Investing in the professional development of housekeeping teams protects patients and staff and delivers significant economic and reputational benefits. 

Magill SS, O’Leary E, Janelle SJ, et al; Emerging Infections Program Hospital Prevalence Survey Team. Changes in prevalence of health care-associated infections in U.S. hospitals

. 2018;379(18):1732-1744. doi:10.1056/NEJMoa1801550

Kundrapu S, Sunkesula V, Jury LA, Sitzlar BM, Donskey CJ. Daily disinfection of high-touch surfaces in isolation rooms to reduce contamination of healthcare workers’ hands

. 2012;33(10):1039-1042. doi:10.1086/667730

Blanding M. What drives managers to sabotage talented employees. Harvard Business School. January 9, 2025. Accessed January 18, 2025. https://www.library.hbs.edu/working-knowledge/what-drives-managers-to-sabotage-talented-employees

Carling PC, Parry MF, Von Beheren SM; Healthcare Environmental Hygiene Study Group. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals

Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system

. 2013;173(22):2039-2046. doi:10.1001/jamainternmed.2013.9763

This article explores why it is essential to train housekeeping staff and leaders in health care facilities, emphasizing key reasons and evidence-based practices to back this necessity.

Optimizing Training for Environmental Services Staff: A Critical Component of Patient Safety and Infection Control

The use of ambulatory health care facilities for minor surgical procedures is projected to grow by at least 25% at ambulatory surgery centers (ASCs) and 18% at hospital outpatient departments and physician offices over the next 10 years.

 ASCs have the most substantial projected increase due to patient savings. The average price of standard procedures performed in a hospital in 2019 was $7716, which is nearly 144% higher than the average price of the exact procedures performed in ASCs.

 This savings is only valid if a surgical site infection (SSI) does not occur.

The CDC defines SSI as “infection related to an operative procedure that occurs at or near the surgical incision within 30 or 90 days of the procedure, depending on the type of procedure performed.”

 SSIs are a significant concern associated with every surgical procedure regardless of their complexity, as they may enact a considerable economic burden and increase morbidity and mortality rates. Outpatient SSIs can result in prolonged hospital stays that can last 7 to 10 days, resulting in $20,000 to $27,600 in costs per admission.

 The astronomical figures associated with an SSI provide a significant indication for prevention efforts. When considering approaches to SSI prevention, it is essential to address the variety of perioperative opportunities available to improve patient safety during outpatient procedures while acknowledging the multidisciplinary collaboration needed to implement multiple effective strategies simultaneously.

Every patient who enters a health care facility for a surgical procedure is at risk of developing an SSI. SSIs are among the most avoidable health care–associated infections but only with focused attention to all aspects of a surgical procedure. Delineating the 3 subsections of perioperative processes (pre-, intra-, and postoperative) emphasizes the importance of evidence-based guidelines in SSI prevention while incorporating the unique cross section of disciplines involved in executing surgical procedures even within ASCs.

Several accepted risk factors for SSIs are based on the patient. These patient-related risk factors, whether modifiable or nonmodifiable, provide a solid foundation for addressing preoperative strategies to mitigate the burden of SSIs. Patient-related factors that influence the risk for SSIs include nonmodifiable variables, such as age or sex. There is evidence that supports the fact that older patients may have comorbidities that can increase their risk for SSIs due to reduced immune function.

Also, specific factors related to sex, determined by a patient’s biological characteristics, might influence surgery type and frequency, resulting in an increased SSI risk. The modifiable lifestyle behaviors of patients, including substance use (ie, alcohol, tobacco, and illicit drug use), diet, and exercise, can actively contribute to the development of SSIs.

 Smoking, alcohol misuse, and obesity are known to have a grave impact on immune function, consequently also affecting the wounds associated with surgical procedures. The oxygen supply to tissues, which is necessary for healing, is impaired by smoking.

 The results of alcoholism are malnutrition and a weakened immune response, whereas obesity can also complicate the wound-healing process and increase the susceptibility of a patient to infections of the tissues.

 Identifying these risk factors in patients allows for appropriate care management throughout the procedure.

Preoperative antibiotics are justified when the risk of infection is high or if there is a high risk of adverse outcomes specific to the procedure being performed, as seen with cardiac procedures and/or implantation of a foreign device. The rationale behind antimicrobial prophylaxis hinges on its ability to prevent SSIs by reducing the microorganism burden that can occur at the surgical site during the operative procedure. Patients who receive prophylactic antibiotics within 1 to 2 hours before the initial incision of their procedure are at a decreased risk of developing an SSI compared with patients who receive antibiotics sooner or later than this time window.

 When antimicrobial prophylaxis is employed appropriately, there is an increased likelihood of preventing SSIs, morbidity, and mortality; reducing the duration and cost of health care; causing minimal adverse drug effects; and having minimal adverse effects on the microbial flora of the patient or the health care environment.

Contamination by instruments or room air is less likely to cause an SSI than the patient’s normal skin flora. Before a surgical procedure, skin preparation plays a vital role in reducing normal skin flora bioburden.

 Because of its histologic structure, human skin cannot be sterilized even by intense disinfection; therefore, surgical skin preparation aims to reduce bacterial colonization.

 The reduction of bacterial colonization depends primarily on concentration and exposure to the antiseptic agent, given that skin cannot be sterilized. This evidence suggests that surgical skin preparation should be optimized to minimize the intrusion of normal skin flora during procedures, but other strategies must also be considered.

Intraoperative interventions for reducing SSIs are primarily focused on skin decontamination for patients and health care workers, using barriers to prevent the movement of microorganisms into incisions and optimizing the patient’s bodily functions to improve recovery.

The patients’ skin is disinfected in the procedure room using antiseptic solutions such as povidone‐iodine or chlorhexidine at varying concentrations. The aim of these skin antiseptic agents for patients is to reduce the risk of SSIs by reducing the number of microorganisms on the skin.

 The CDC recommends that surgical personnel perform surgical hand/forearm antisepsis according to the product manufacturer’s recommendations and remove debris from underneath fingernails using a nail cleaner under running water. Surgical hand antisepsis using an antimicrobial soap or an alcohol-based hand rub with persistent activity is also recommended. Health care workers have multiple opportunities to practice hand hygiene during perioperative patient care.

In addition to preparing a patient’s skin for surgery, sterile drapes are used as a barrier to protect the patient from their skin flora and contamination from the surgical team members and environment.

 Before a surgical incision, sterile drapes can be placed onto the patient’s decontaminated skin. The Association of Surgical Technologists (AST) has developed the AST Standards of Practice for Surgical Drapes to support health care facilities in reinforcing best practices related to surgical drapes.

Various coverings worn during a procedure are designed to act as a barrier between the environment and the patient’s wound to maintain a sterile procedural field, such as masks that aim to contain any droplets being expelled by the surgical staff.

 Shoe coverings aim to limit the transfer of external material in and out of the procedure room. Gowns cover the designated attire of the surgical staff and can be removed when contaminated and replaced. Surgical staff wear disposable gloves during surgery to prevent the transfer of microorganisms from the staff member’s skin to the patient’s skin or surgical incision.

During the surgical procedure, the patient’s bodily functions must be optimized to promote recovery and reduce the risk of SSI.

 Under general anesthesia, the risk of perioperative hypothermia increases because the body finds it more difficult to regulate temperature in these conditions. Instituting appropriate warming methods to maintain body temperature and prevent the development of perioperative hypothermia, which can prevent postoperative outcomes, to include an SSI. Also, during surgical procedures requiring general anesthesia, the patient is intubated and supplied with oxygen to maintain adequate oxygen perfusion to all tissues; however, if oxygenation is not at optimal levels during surgery, there is an increased risk of an SSI.

 Strict glycemic control using medications to maintain glucose levels during surgery can reduce the risk of surgical complications, including infection.

Surgical wound and incision management in the postoperative period is imperative to prevent complications, including SSI and wound dehiscence (wound source). Appropriate cleansing, skin care, and moisture management should be an essential part of surgical patients’ postoperative care plans. Regular dressing changes and monitoring for signs of infection are pivotal during this period in preventing SSIs.

Encouraging mobilization during the postoperative period supports blood circulation and reduces the risk of infection.

 When patients are mobile, blood can circulate and deliver oxygen and nutrients to the wound site, supporting healing and reducing the chance of infection. Early mobilization can also have broader benefits for patients, including reduced risk of complications such as pneumonia and blood clots and faster recovery times.

In ASCs, the heterogeneity in procedures, roles of the patient care team, and patient populations makes it difficult to define the most appropriate structure or model for optimal team-based health care. Because many factors increase patients’ risk of SSI along the surgical pathway, engaging all the health care workers within the ASC is crucial. Implementing multidisciplinary strategies in SSI prevention must be consistently applied, responsive to the individual patient’s needs, and supported by the health care organization.

Successful implementation of these perioperative strategies could be attributed to increasing awareness of the individual measures but, most importantly, to the patient care team’s adherence to these measures.

 Preventing SSI is a complex endeavor requiring a multidisciplinary approach. A cultural shift acknowledging appropriate perioperative strategies that capitalize on the expertise of various groups, including the patient, can make SSI prevention measures effective and achievable.

Taylor DL III. Planning for surgery’s future: ambulatory surgery centers expected to skyrocket. OR Management News. January 1, 2024. Accessed January 25, 2025. https://www.ormanagement.net/Opinion/Article/12-23/Planning-for-Surgerys-Future-Ambulatory-Surgery-Centers-Expected-to-Skyrocket/72398

Lagasse J. Shifting common outpatient procedures to ASCs shows cost savings. Healthcare Finance. September 9, 2021. Accessed January 25, 2025. https://www.healthcarefinancenews.com/news/shifting-common-outpatient-procedures-ascs-can-save-consumers-more-680-procedure

. CDC. January 2025. Accessed January 25, 2025. http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf

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Bucataru A, Balasoiu M, Ghenea AE, et al. Factors contributing to surgical site infections: a comprehensive systematic review of etiology and risk factors. 

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Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: surgical site infection guidelines, 2016 update. 

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Kean J. The effects of smoking on the wound healing process. 

As surgical procedures shift increasingly to ambulatory care settings, preventing surgical site infections is more critical than ever to protect patients and reduce avoidable costs.

Infection Control Today, March/April 2025 (Vol. 29 No.2)

Beyond Hand Hygiene: The 5 Critical Moments for Environmental Disinfection in Health Care

Silent Saboteurs: Managing Endotoxins for Sepsis-Free Sterilization

Optimizing Training for Environmental Services Staff: A Critical Component of Patient Safety and Infection Control

Increased Use of Ambulatory Surgery Centers Demands SSI Prevention

Silent Threat: The Overlooked Infection Crisis in Dialysis Patients

The Guardians of Animal Health: Who Are Veterinary Infection Preventionists?

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