In 1998, the CDC published guidelines and recommendations for infection control in healthcare personnel and then updated them in 2019 (CDC, 2019). These guidelines provide recommendations on how to assess risks among healthcare workers (HCWs), complete a medical evaluation, provide infection control and prevention training, implement an immunization program, and manage potentially infectious exposures (CDC, 2019). Management of job-related illnesses and exposures for HCWs with certain infectious diseases can be found in table three of the 1998 guideline (CDC, 1998). Note that the CDC has not added SARS-CoV-2 to the HCW guidance; therefore, refer to the Interim Guidance for Managing Healthcare Personnel with SARS-Cov infection or exposure (updated in September 2022; CDC, 2022).
Universal precautions and body substance isolation recommendations were combined into what we now call standard precautions. Standard precautions are essential for all healthcare personnel in all healthcare settings that provide clinical patient care (CDC, 2016). To prevent transmission of infections to other patients and healthcare personnel, these basic precautions should be adhered to regardless of the patient’s medical condition or infection status. Adhering to standard precautions also provides protection in situations that are not applicable under the universal and bloodborne pathogen standards. For example, under standard precautions, all bodily fluids are considered potential sources of infectious material (OSHA, n.d.b).
HEALTHCARE-ASSOCIATED INFECTIONS
A nosocomial infection is acquired in a hospital, whereas a healthcare-associated infection (HAI) may be acquired in any healthcare setting. An HAI is an infection occurring on or after day three of admission (day one) to a healthcare setting without signs and symptoms of an infection incubating at the time of admission (CDC, 2022). Healthcare facilities follow infection control surveillance guidelines to consistently monitor patterns and trends as well as report infection rates. All healthcare workers should know the most common HAIs in their facility and the strategies implemented to reduce those infections. According to the CDC, an estimated 1 in 31 patients develops an HAI in a hospital daily, and 1 in 43 nursing home residents develop an HAI daily (CDC, 2022; Thompson et al., 2020). Skilled nursing and long-term care facilities are congregate living settings, which increases the risk of developing an HAI. They have a vulnerable group of patients (residents). The most common sites of infection (making up 80% of HAIs) are the skin (32%), respiratory tract (29%), and urinary tract (20%; Thompson et al., 2020). Due to limited national comparison infection data for skilled nursing homes, Thompson and colleagues (2020) encouraged using these data to identify high-risk residents and ensure appropriate infection prevention practices. Healthcare-associated infections (HAIs) cause increasing lengths of stay, increased morbidity and mortality, excess patient costs, and increased antibiotic resistance (World Health Organization [WHO], 2009). For the past few years, HAIs have decreased. However, the National and State Healthcare-Associated Infection Progress Report (October 2021) shows an increase in ventilator-associated events (VAE; 35%), central line–associated bloodstream infections (CLABSI; 24%), and hospital-onset methicillin-resistant Staphylococcus aureus (MRSA) and MRSA bloodstream infections (20%) in long-term acute care hospitals (LTACH) from 2019 to 2020 (CDC, 2021). Reductions were seen, however, in Clostridioides difficile and surgical site infections (SSIs). At the beginning of the pandemic, elective surgical procedures were on hold, which could have contributed to the reduction in SSIs. No significant changes were seen in catheter- associated urinary tract infections (CAUTIs). The pandemic brought challenges to implementing routine infection prevention practices, and some facilities saw increased infections. The challenges facilities faced involved dealing with multiple process changes to manage higher-acuity patients, decreased admissions and surgeries, staffing shortages, and inappropriate reuse of PPE (Alsuhaibani et al., 2022; Baker et al., 2021; Fakih et al., 2021; Sturm et al., 2022). During the pandemic surges, many of the usual processes put in place to prevent infections were affected. Fakih and colleagues (2021) evaluated infection prevention practices among 78 U.S. hospitals in an extensive multistate healthcare system. The authors describe alterations in CLABSI prevention practices, such as fewer “line rounds,” line care due to intravenous pumps being placed in the hallways, less
opportunity to scrub the hub, and dressing change gaps. These alterations saw CLABSI rates increase by 51%, mainly in intensive care units (ICUs), and no significant changes in CAUTIs. Similarly, Baker and colleagues (2021) evaluated 148 affiliated hospitals and found a 60% increase in CLABSIs, a 43% increase in CAUTIs, and a 44% increase in MRSA bloodstream infections. The authors suggested that the focus may have been more on preventing the spread of COVID-19, which may have affected device- related infection prevention practices. The increase in PPE use could have contributed to the decrease in C. difficile and other multidrug-resistant organisms (MDROs). There were some benefits from the pandemic. Benefits include improved hand hygiene compliance and increased awareness of personal protective equipment and what to wear based on the activity (e.g., N95 and eye protection for an aerosol-generating procedure (Tsang et al., 2020). Improvements in hand hygiene were seen before patient contact and after contact with the patient’s surroundings. These improvements may have reduced HAIs from MDROs from January to April 2020. In another study, the benefits of the pandemic were a decrease in MRSA, CLABSIs, and healthcare-associated respiratory viral infections from February to August 2020 (Wee et al., 2021). These examples highlight the effect of improving infection prevention practices on HAIs. Lastinger and colleagues (2022) continued to monitor National Health and Safety Network (NHSN) data for any patterns and trends in HAIs during 2021 and found ongoing increases. The authors found CLABSIs, CAUTIs, VAEs, and MRSA bacteremia increased significantly in quarter one when there were increases in hospitalizations and quarter three when the delta variant emerged (which also increased hospitalizations). As COVID-19 becomes endemic, there should be a renewed focus on strengthening infection control programs by ensuring adequate staffing and compensation along with encouraging “outside of the box” thinking (Alsuhaibani et al., 2022). With any patient safety initiative, auditing practices and providing regular and immediate feedback to staff will help improve performance (Fakih et al., 2021). Healthcare Consideration: State-based HAI prevention plans are updated annually and are on the CDC’s website: https:// www.cdc.gov/hai/state-based/state-hai-plans.html. Locate the state you work in and determine what activities are being implemented to reduce HAIs. Additional evidence-based guidance for healthcare facilities includes: ● Surgical site infections (Berrios-Torres et al., 2017). ● Strategies to prevent ventilator-associated pneumonia in acute care hospitals (Klompas et al., 2014). ● Catheter-associated urinary tract infections (CDC, 2009). ● Central line–associated bloodstream infections (CDC, 2011).
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