Infection Prevention: Got Creepy Crawlies in Your ORs?

Flies, roaches and other insects are unsightly... but do they pose an SSI risk?

It’s one of the most undiscussed and unstudied phenomena in surgery, dating back to the very first operations on patients: the presence of insects in the OR and the perioperative suite.

An insect infestation is often considered an unpleasant nuisance that can creep out surgeons, staff and — most importantly for the center’s reputation — patients. A pest control service may be called, areas where bugs were observed may be cleaned, certain equipment and instrumentation may be re-sterilized, and the problem is seemingly addressed.

But there’s a deeper issue when ORs are “buggin’ out.” What potentially infectious materials are these insects leaving behind, and where?

At last year’s Association for Professionals in Infection Control and Epidemiology (APIC) conference, two infection preventionists (IPs) led an interactive session with dozens of their peers to shine a bright light on insect infestations in surgical environments, not only to share best practices, but also to raise the alarm that so much remains unknown about the true impact of these events in terms of patient safety and infection prevention.

Knowledge gap

“Everybody needs a plan for what to do if there is an infestation that isn’t just ‘call pest control,’ but what else?” says Stephanie Stroever, PhD, MPH, an assistant professor at Texas Tech University Health Sciences Center in Lubbock with ample experience as a certified IP, who led the session with Krystal Hill, BSN, RN, CIC, infection control surveillance coordinator with Northwest Texas Healthcare System. “Is it a matter of just closing that one OR and cleaning really well, or what else do we need to do?”

Dr. Stroever and Ms. Hill described their own insect experience during the session, a sewer fly infestation in ORs and the sterile core, which were terminally cleaned. As IPs, however, they felt the problem might not have been fully addressed, as insects they observed on sterile packs were brought from other areas into the OR. “We didn’t know what all the insects had been on,” says Dr. Stroever. “The packs that had gook on them where the insect died were reprocessed. But we had all these wrapped instruments where we couldn’t decide, ‘Are they compromised or not?’ We didn’t know if the insect was on that one over there, or this one. If I could have, I would have reprocessed everything because I just didn’t have enough information.”

However, IPs usually can’t close ORs or order mass reprocessing based on a hunch. Given the glaring lack of evidence-based research on the topic, that’s all it really was – a hunch.

“In this specific situation, it was really frustrating to try and communicate to C-suite, bedside staff, anybody involved that there was danger here. It was even scarier to think we could be introducing new microbes into our hospital environment that could find little nooks and crannies to thrive,” says Ms. Hill. “Even if we don’t have a patient with an SSI potentially linked to these bugs, who knows what can happen years down the road? The risk seemed monumental, but from an operational standpoint, it just wasn’t justified to do the things that would make us feel better.”

Dr. Stroever recalls one comment from the session evaluation that stuck with her and Ms. Hill. “We got great feedback, but one comment said, ‘We really wish you would have told us what to do, as in, ‘OK, here’s the right answer,’” she says. “That’s the problem. There’s not enough evidence to have the right answer.”

‘Just don’t have bugs’

Dr. Stroever says some basic guidance exists. “CDC essentially says ‘just don’t have bugs’ and get pest management to come to take care of an infestation,” she says. “The Joint Commission requires an integrated pest management plan. It’s kind of ‘just figure it out.’ Where we get into questions is — ‘Now that we have them, what do we do?’ Sure, we’ll take care of them, but they’ve still been here. What is left behind?

“That’s where the gap is in the literature. Nobody has taken the next step to say, ‘What’s the risk to patients?’ Most places have breaches and don’t communicate about them,” says Dr. Stroever. “Nobody wants to say their hospital had bugs. It’s not good for business.”

Dr. Stroever and Ms. Hill hope their APIC session and articles like this one can spur funding for more rigorous study of the true impact of insect infestations, which could then lead to detailed guidance for IPs and facilities.

Breadcrumb trail

A tremendous amount of research confirms that insects carry bacteria and pathogens, including multidrug-resistant ones, in their travels on surfaces and through the air, as well as in the feces they leave behind. As such, the potentially infectious reach of an infestation can be widespread throughout the facility, not just where pests are observed.

Psychology and culture often drive how infestations are regarded. In developed nations like the U.S., the potentially infectious danger they present is often rationalized away. In developing countries, however, there is much more acute awareness, as Dr. Stroever witnessed during a mission trip to Guatemala.

“We’ll take care of them, but they’ve still been here. Whatis left behind? That’s where the gap is in the literature.”
– Stephanie Stroever, PhD, MPH

“People there worked so hard to keep flies off their food,” she says. “They know if a fly lands on it, they very likely can get parasites. What I see in the literature from developing or middle-income countries is that they recognize we need to keep pests out. A lot of research is coming out of Brazil about ants and cockroaches, and from Europe and the Middle East about flies and cockroaches. As Americans, most of us don’t live in challenging environments, and we just don’t think as much about it.”

Ms. Hill says American providers’ and facilities’ reactions to bugs in the surgical suite reflect this disconnect. “It’s almost this bizarre double standard we have in our head with bugs,” she says. “We don’t want them, we think they’re gross, we know they’re dirty, but we don’t want to admit when they’re in our spaces, so we kind of overlook it. At home, you’ll call the pest control person or set out traps or get a sticky strip, but you don’t want to admit, ‘My house is dirty from this.’

“Some of that double standard comes into your workplace, like the OR,” she says. “When you see something, it’s like you turn blinders on: ‘This is still a clean, sterile space, because I would not work somewhere that’s not clean and sterile.’ It’s not because they’re lazy or don’t care or don’t know. It’s just because the [potential danger] hasn’t been identified.”

Difficult conversations

Infestations at freestanding ASCs, many of which don’t employ dedicated IPs, pose additional concerns. “Often, the designs of those facilities didn’t necessarily have infection in mind,” says Ms. Hill, noting many renovated buildings weren’t originally purpose-built for health care or surgery. “But there are still ways to mitigate those risks even after design decisions have been made.”

When insects are observed, the issue must be brought to leadership. “Somebody needs to raise the alert, whether it’s the OR director or coordinator, whoever that may be,” says Dr. Stroever.

Those conversations can be delicate and even frustrating, but are necessary. Dr. Stroever says the C-suite often responds by requesting evidence that the infestation can cause patient infections. “They need concrete data,” she says. “They want you to show them what we’re supposed to do.”

That’s where the lack of evidence-based studies comes into play. “We need more information to justify shutting down these uncertain spaces,” says Dr. Stroever. “Things that were very clearly contaminated will be reprocessed, no question. It’s the other stuff.” She cites examples:

• Breakrooms contain food and trash.
• Areas around autoclaves are moist.
• Shipping boxes attract roaches that eat glue.

The problem, she says, is that if bugs are seen in these areas, nothing is really stopping them or the contaminants they carry from entering the surgical suite — especially when sterile packs are transported there from areas where bugs have been observed.

“From an operational and feasibility standpoint, one could argue everything is dirty,” says Dr. Stroever. “Just because the insect is on something now doesn’t mean it didn’t also sit on a nasty dock or on a truck that had flies before it got here. It could be endless.

“We make water risk assessments, utility risk assessments, and we are able to quantify the risk,” says Dr. Stroever. “We do a yearly infection control risk assessment, and I feel pests need to be on there. We need some sort of tiered system where if we hit this score and over, we take one action, versus this score and under is where we take this other action. I think this would be super helpful for those conversations with leadership.”

Adds Ms. Hill, “It’s important to recognize when you’re working with different departments and the C-suite, they all want what’s best for the patient. You all come together with your different priorities, and then find that middle point where everybody is taken care of appropriately to our best ability, with the best knowledge we have at the time.”

Maintain your standard

Ms. Hill says providers should never view the presence of insects as normal. “Don’t turn a blind eye to it and think, ‘This is just what we have to work with,’” she says. “Find ways to help those spaces be what you really want them to be: super-clean, sterile spaces that are safe for patients to have their bodies opened and operated on.”

Ms. Hill wants leaders and staff to keep in mind how small these pathogens can be and how little space they take up. “It’s microscopic. A lot can live in a very small space, and these bugs are not living and dying all in one small area,” she says. “If you encounter bugs, put aside the shame and really think about it. How did they get there? Where could they all have been? What is best for patients, the community and staff? Think about the risk of infection these bugs pose, not just now to the patients who were in those spaces, but your ecosystem that you cannot see, and how these bugs have possibly brought a brand-new organism into it that is interacting with other bugs and acquiring resistance powerups.”

Ms. Hill urges facilities to bring an “IP imagination” to their risk assessments to mitigate, prevent or handle infestation events.

“You’ll often hear, ‘It’s everybody’s job to keep the facility clean, so if you see something, say something,’” she says. “That’s not just about a spill on the floor, or trash overflowing. It could be a fly.” OSM