Joan Blanchard
Nancy Chobin
The perioperative setting has changed in healthcare facilities as regulatory requirements and agency recommendations continue to increase and the effect of healthcare personnel shortages is felt. The perioperative environment still is considered high risk for both the patient and the surgical team [1]. More than 90,000 patient deaths annually result from adverse events [2]. The second most common cause of healthcare-associated infection (HAI) is surgical site infection (SSI). Morbidity, mortality, and increased healthcare costs related to SSIs are of considerable concern [3]. The costs of an SSI can be significant; an SSI caused by methicillin-resistant Staphylococcus aureus (MRSA) can be as much as $92,363 or more [4]. Approximately 27 million people have surgery annually; about 500,000 of these patients will acquire an HAI [5]. It is estimated that 40% to 60% of SSIs are preventable [3].
Regulatory and recommending agencies are working closely with each other to change those statistics. These agencies and associations are represented by the American College of Surgeons (ACS), American Society of Anesthesia (ASA), Association of periOperative Registered Nurses (AORN), Association for Professionals in Infection Control and Epidemiology (APIC), Society for Healthcare Epidemiology (SHEA), Centers for Medicare and Medicaid (CMS), Joint Commission (JC), Centers for Disease Control and Prevention (CDC), and American Hospital Association (AHA), to name a few.
The JC works with the Sentinel Event Advisory Group to review pertinent literature and reports and identifies patient safety goals and requirements. In addition, the JC has created separate National Patient Safety Goals (NPSGs) for both inpatient and ambulatory healthcare facilities. The NPSGs were created to improve patient safety and may change each year [6].
The safety goal that applies to infection control is NPSG [7] to reduce the risk of healthcare-associated infections. This goal outlines measures to reduce the transmission of pathogens from staff members to patients and complies with the CDC hand hygiene guidelines. In addition to HAIs, it addresses any infection that may result in the unanticipated death of a patient or any patient infection that may result in a loss of function or may become permanent. These infections must be reported as a sentinel event. A root cause analysis should be performed to establish what systems processes were in place that led to the occurrence [7].
The JC tracks sentinel events; however, due to poor reporting by healthcare facilities, the actual statistics concerning these events are unknown. The actual number of SSIs that cause sustained loss of function may be higher than currently accepted. All of these issues identify the increased hazards to patients and staff members in the operating room [8].
Operating Room (OR) HAI Surveillance
Exposure to blood, body fluid, and pathogens is common in the operating room (OR). The risk of transmitting a pathogen to an otherwise healthy patient exists as does the possibility of adding to the morbidity and mortality of already ill patients. As a result, classification systems have been developed to alert staff members to a patient's risk for an adverse event.
SSI Risk Stratification
The CDC's National Nosocomial Infections Surveillance (NNIS) system developed and uses an SSI risk index ranging from zero to three points. The patient's risk index points are assigned based on the surgical wound
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classification, ASA classification system, and length of the surgical procedure [9].
Surgical Wound Classification
Wound classification should be made at the time of the operative procedure by the surgeon performing the procedure and documented by the circulating registered nurse as follows:
ASA Classification System
The ASA uses a point system to rate or classify the patient's health or condition before surgery. The patient assessment is done by the anesthesia care provider (Table 26-1) [12].
Length of Surgical Procedure
Classifying a patient based on the length of a procedure is done after the procedure. Risk increases as the time of the procedure increases. If the total time for a surgical procedure extends beyond T hours (when T is the 75th percentile of the total time for procedures of that type), then the higher number of points equals the greater SSI risk [9].
The CDC defines SSIs that occur within 30 days of surgical procedures without an implant to be considered HAIs. In procedures with an implant placed, infections within one year of surgery are considered HAIs if the implant remains in place [13].
The CDC's NNIS has developed standardized surveillance definitions of SSIs (Figure 26-1). Consistently using recognized definitions of SSIs provides perioperative personnel with important data to change practice patterns and protect patients from acquiring HAIs [13].
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TABLE 26-1 |
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Microorganisms Identified in the Perioperative Setting
According to the CDC's NNIS, pathogens causing SSIs include the following:
Many of the pathogens causing SSIs are from endogenous sources that may come from the patient's own skin, mucous membranes, or hollow viscera. Exogenous sources also can cause SSIs. These include surgical team members, equipment, instruments, or contaminated supplies on the sterile field used during the surgical procedure [14]. Preoperative colonization of the patient's nares with Staphylococcus aureus also can increase the risk of contracting an SSI [13].
Patient populations at greatest risk for developing an SSI include those who
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Figure 26-1 Criteria for defining a surgical infection. |
Knowing which patients are most at risk for developing SSIs and understanding the possible sources of pathogen transmission may help surgical team members protect patients and prevent SSIs. Using antibiotic prophylaxis appropriately, maintaining patients' temperatures, controlling patients' glucose levels, using clippers to remove hair, and adhering to the principles of asepsis are all proactive measures for preventing SSIs [15].
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Modes of Perioperative Pathogen Transmission
HAIs originating in the perioperative suite, in general, result from a break in aseptic technique. It is impossible to exclude all microorganisms from the OR environment. For the safety of both patients and personnel, therefore, every effort should be made to minimize patient exposure to these microorganisms [16]. Perioperative personnel must be scrupulous in their aseptic technique and ensure that their practice is based on valid evidence-based research and supported by their professional organization. They must be familiar with their standards of practice and be aware of any breaks in technique. Every attempt must be made to provide quality care to patients and prevent the occurrence of adverse events.
Concerns have been raised that some common perioperative practices may result in patient HAIs. The following demonstrates how devastating poor aseptic practice habits can be to patients. The anesthesia care provider practice of administering medications to multiple patients from the same syringe, for example, is of concern. Even if the needle on the syringe has been changed, repeated use of the same syringe is never advisable [17]. A Hepatitis C outbreak in 52 patients at one hospital occurred as a result of the reuse of needles and syringes in October 2002 [18]. The anesthesia care provider was injecting medication into the intravenous (IV) tubing of multiple patients using the same syringe and needle. This practice was investigated and the risk of transmitting infection from patient to patient was studied. The blood contamination rate in IV tubing was 3.3% at the injection site and 0.3% farther away from the injection site. Having a one-way valve made no difference. It has also been found that even if the needle had been changed but the syringe had not, this did not reduce HAI rates [19]. A survey of 2,530 anesthesiologists in 1995 found that 39% reported reusing syringes from patient to patient. Another 1995 study found that 20% of anesthesiologists reused syringes from patient to patient, and 34% often did not disinfect the stopper on multidose vials [20].
The ASA recommendations for infection control for the practice of anesthesiology support the practice of using aseptic technique, using multiuse vials appropriately, and not reusing syringes and needles [21]. Preventing contamination of medications requires safe handling of parenteral medications to prevent HAIs in patients undergoing anesthesia or sedation. Many factors can influence contamination of medications that are likely to support the growth of organisms. Preservative-free medication ampules, vials, and prefilled syringes for single-patient, single-dose use should be checked for the presence of preservative agents. Single-use ampules and vials should be discarded after the content has been drawn up. Prefilled syringes should be discarded after they are used because a single dose ampule, vial, or prefilled syringe contains medication intended for single use only and generally does not contain the bacteriostatic or preservative agents found in multidose vials. Additionally, the CDC Guidelines recommend that medications be drawn up as close to administration time as possible. These medications may become contaminated with bacteria or other microorganisms from nonsterile glass fragments, airborne contaminants, or failure to use aseptic technique. Postoperative fever, infection, sepsis, or other life-threatening illnesses and death have been reported after extrinsic contamination of propofol [22].
Syringes and needles are single-use sterile items as well. Medication from a syringe must not be administered to multiple patients even if the needle is changed. Connecting or entering a patient's IV infusion line contaminates these items. All used needles and syringes should be discarded immediately into a sharps container. Using single-use needles and syringes prevents a siphoning effect that aspirates the needle contents into the syringe when the needle is removed. A needle with viral or bacterial contamination will contaminate the syringe even if the needle is flushed before removing it from the syringe.
Blood-borne pathogens may contaminate the syringe when used with IV, intramuscular, or subcutaneous administration of medication. If backflow occurs during blood sample aspiration or from a transfusion, this also could lead to contamination. Reuse of syringes and needles puts patients at risk for cross-contamination and increases HCWs' risks if a needle-stick injury occurs [21].
Multidose vials may have suspected or visible contamination, and if so, should be discarded. For example, HAI outbreaks, including hepatitis B, have been traced to extrinsically contaminated multidose vials. Breaks in aseptic technique can introduce microbial contamination into the vial via the needle, syringe, or rubber stopper. Viral particles may survive in some multidose vials for at least one day. Outdated multidose vials should be discarded [21].
Means of Monitoring Perioperative SSIs
The CMS has been engaged since 2002 in active efforts to decrease SSIs by initiating two projects, the Surgical Infection Prevention (SIP) project and the national Surgical Care Improvement (SCIP) project [23]. The SCIP project is a national quality partnership of organizations that have made efforts to improve surgical patient care using evidence-based practice recommendations. The SCIP project followed the SIP.
The mission of this collaborative effort is to create systems that decrease SSI rates, which hospitals can do by implementing a systemwide model of care [24]. One goal within the CMS SIP project is to decrease morbidity and mortality associated with postoperative SSIs in the Medicare patient population by promoting the appropriate selection and timing of the administration of prophylactic
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antibiotics. A panel of multidisciplinary experts developed three performance measures for national surveillance and quality improvement:
The outcome indicators are to
The Quality Improvement Organization (QIO), formerly known as the Peer Review Organization in each state, will work with hospitals to improve these SSI prevention practice indicators. The QIOs assist healthcare facilities in providing high-quality care by educating, analyzing data, providing quality improvement tools and techniques, and facilitating hospital compliance with the guidelines to enhance patient care and safety.
Hospitals may select other practices, such as maintaining patients' normothermia, glucose control, and oxygenation; hair removal with clippers; and other SSI prevention procedures. The procedures to be tracked are those commonly performed on Medicare patients: coronary artery bypass grafting; other open chest surgery; vascular surgery, including aneurysm repair; thromboendarterectomy and vein bypass procedures; hip and knee joint arthroplasty, excluding revision surgery; general abdominal colorectal surgery; and abdominal and vaginal hysterectomy [24].
This project uses evidence-based research. Hospitals must become involved and play a significant part in contributing to the prevention of SSIs. For more information regarding the SIP Project, visit www.medqic.org/sip.
The national SCIP project is derived from data accumulated in the SIP Project; it is a national quality partnership of organizations that have made efforts to improve surgical patient care using evidence-based practice recommendations [25]. The SCIP process and outcome measures for SSI prevention include these:
SCIP also includes additional measures for cardiac, venous thromboembolism, and respiratory conditions. These make up the Interpretive Guideline Update [26]. For more information, visit the SCIP Questions & answers for hospital quality improvement at www.medqic.org/scip/pdf/Q&A%20QIs%2007-05.pdf.
The following are some examples of improvements made by healthcare partners involved in SCIP:
For more information, visit the Medicare Quality Improvement Community at http://www.qnetquest.org/quest/index.do?mode=96&image=http://www.medqic.org/dcs/mq/images/medqic_banner_quest.gif.
Prevention of Nosocomial SSIs
Perioperative personnel can do the following things to prevent or reduce SSIs in patients under their care.
Hand Hygiene and the Surgical Scrub
Hands can be a major source of transient flora (i.e., major vectors of cross contamination) [29]. Hand hygiene should be performed before and after patient contact, after removing gloves, before and after eating, before and after using the restroom, and any time that there is a possibility that hands have come in contact with blood or body fluids.
Hand rubs containing ≥60% alcohol have been recommended for use by the CDC in healthcare facilities. Access to scrub facilities or hand rubs must be convenient for staff member compliance. The National Fire Protection Association has added an amendment that now allows alcohol hand rubs in egress corridors. On March 25, 2006, the CMS filed an interim final rule approving the use of alcohol hand rubs in corridors. Local or state fire codes should be checked for requirements on alcohol hand rubs in healthcare facilities [30]. Placing these hand rubs in corridors should add to the ease of use for personnel and thus help to decrease the risk of pathogen transmission via the hands of HCWs.
The intent of hand antisepsis is to decrease any soil and transient pathogens that are on hands, nails, and forearms;
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decrease resident pathogens; and reduce return growth of pathogens. The result of using an antiseptic should be a decrease in pathogens on intact skin. An antiseptic should be nonirritating, antimicrobial, broad spectrum, fast acting, and have a long-acting effect.
When using brushless hand scrubs, hands should be washed with soap and water first if they are visibly soiled. Hand scrub can be applied after washing. Data show that there may be better compliance when U.S. Food and Drug Administration (FDA)–compliant alcohol-based hand rubs are available rather than the traditional scrubs with brushes. Continued scrubbing with brushes can cause skin damage and encourage growing counts of gram-negative bacteria and Candida [29].
Jewelry (e.g., rings, watches, bracelets) should be removed before washing or scrubbing hands. The Chicago Antimicrobial Resistance Project (CARP) studied the use of three randomly chosen hand hygiene products. Hands were cultured before and after hand hygiene. The study revealed there was a 10-fold increase in skin organisms on nurses who were wearing rings. The pathogens that were isolated were S. aureus, gram-negative bacilli, and Candida species. If more than one ring is worn, there is increased risk of contamination [31,32,33].
Nail care is an important part of hand hygiene. Most of the microorganisms on the hands are in the subungual area on the hands. Use of a nail cleaner to remove the collected debris is important, especially under nails that are long. Long nails are a hazard that can cause injury to patients when moving or positioning them and can cause tears in gloves. Wearing artificial nails in the perioperative area has been associated with SSI outbreaks and may increase the risk of SSIs. Moisture can remain between the natural and the artificial nail, providing a good medium for microorganisms to grow. Gram-negative microorganisms (i.e., Serratia marcescens) have been cultured under these nails; fungal infections also can occur [13,34].
Preoperative Patient Skin Preparation
An assessment of hair at the surgical site should be done before hair removal. The amount of hair, area of the incision, and type of procedure should be determined. If hair must be removed, it should be performed by a person skilled in hair removal, outside the OR, and in a way that preserves the patient's privacy and comfort. Hair clippers provide less irritation and are easier to use to achieve effective hair removal. Razors should not be used. Clippers provide the least irritating and easiest way to achieve hair removal. Depilatories may cause skin reactions [13,35]. Testing for possible allergic reaction to the depilatory should be done before applying it. Manufacturer's guidelines should be followed.
Several antiseptic skin preparation products for surgical preps are available, but no comparative studies have been done to provide sufficient evidence that one product should be used over another. In choosing an antiseptic, refer to current research as well as the CDC, APIC, and FDA guidelines [35]. In preparing the patient's skin, keep the following recommendations in mind.
Surgical Attire
Surgical attire consists of freshly laundered scrub clothes, a head cover or hood, and shoes that are clean, have no visible debris on them, and provide foot protection. Masks are worn wherever sterile supplies or scrubbed persons are present. Scrub clothes should be made of low-linting material that helps contain bacterial shedding. Warm-up jackets (i.e., long-sleeved jackets) that button or snap should be worn by nonscrubbed staff members. Jackets made of fleece are not appropriate because they are flammable and attract lint [13,34]. Surgical attire should be changed every day or when items become soiled, contaminated, or wet. Scrub clothing that is contaminated with blood/body fluids must remain at the healthcare facility to be laundered there or at a healthcare facility–approved laundry. This decreases the possibility of transmitting pathogens from the healthcare facility to HCWs' homes or to the public. Reusable scrub clothing should be placed in an assigned hamper for laundering after use [34]. AORN does not recommend home laundering.
Head Cover
Head covers or hoods should be made of low-linting material and should be changed daily. A head cover or hood helps to contain hair and decreases the possibility of hair or dandruff falling on surgical attire, on the sterile field, or in to a surgical wound. Bald or shaved heads must be covered to prevent epidermal shedding. Hair can serve
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as a filter and collect bacteria if left uncovered. Single-use head coverings should be disposed of at the end of the shift. Reusable head coverings should be placed in the appropriate hamper for laundering after use [32,34].
Masks
Masks that cover both the wearer's nose and mouth should be worn. Ties need to be secured to prevent venting. The purpose of the mask is to contain droplets or microorganisms from escaping [34]. According to the Occupational Safety and Health Administration (OSHA) Final Rule, masks are required and must be worn whenever splashes, spray or spatter, droplets of blood, or body fluids that may be potentially infectious and could contaminate the eyes, nose, or mouth can be anticipated [36]. Opinions may differ regarding the effectiveness of masks [37,38].
When removing masks, HCWs should remove them carefully to prevent possible pathogens from contaminating their hands. Masks should not be allowed to hang down around the neck or be placed in a pocket for later use. They should be discarded after use by handling only the ties or elastic [13,32,39].
With airborne diseases (e.g., Mycobacterium tuberculosis), OSHA requires that respiratory protection be certified by the National Institute for Occupational Safety and Health and the CDC. This level of particulate filter respirator (i.e., N-, R-, or P-95, 99, or 100) includes respirators that are disposable or powered air-purifying respirators (PAPRs). Particulate filter respirators (N-, R-, or P-95, 99, or 100) must be fitted to the wearer's face [40].
Gowns
Gowns should be made of protective material that is liquid resistant to prevent exposure to blood/body fluids that may be infectious [41]. The surgical team members wear sterile gowns to assist in maintaining a sterile field. Gowns may be reusable or disposable and must meet the standards set by the American Society for Testing and Materials (ASTM) [13].
Gloves
Glove selection should be based on the tasks to be performed. Sterile gloves are selected when performing sterile procedures, and nonsterile gloves are used for nonsterile procedures. Gloves help reduce gross contamination of the hands and need to be changed between patient procedures or contacts to prevent microorganism transmission. Hand hygiene should be performed after gloves are removed [34]. Gloves should be changed as soon as holes or tears are apparent. Double gloving (i.e, wearing two pairs of gloves) decreases the possibility of a bloodborne pathogen exposure [13].
Eyewear
HCWs should wear eyewear that forms a protective barrier over the eyes to prevent splashes, splatters, or sprays from contaminating the eyes when there is any possibility of this occurring. When the eyewear becomes contaminated, HCWs should discard or decontaminate them [34].
Shoe Covers
Wearing fluid-resistant shoe covers to prevent splashes or spills from contaminating the shoes is considered part of the Personal Protective Equipment (PPE) requirement when procedures involve irrigation or profuse loss of body fluids (e.g., orthopedic trauma, cases). Shoe covers assists in keeping the HCWs' feet dry [42]. There is no evidence that shoe covers reduce the incidence of SSIs. If shoe covers develop tears, holes, or become wet, they should be removed and replaced. Before leaving the perioperative area, HCWs should discard shoe covers [34].
Environmental Cleaning
Patients having an invasive procedure should be ensured a clean environment. Cleaning the OR should be done on a regular schedule to decrease dust, soil, and the microbial load that occurs in this setting. ORs should be cleaned at the beginning of the day and between each surgical patient. Terminal cleaning should be done at the end of the day. An Environmental Protection Agency (EPA)–registered hospital disinfectant should be used for cleaning. Manufacturer's guidelines should be followed. Alcohol should not be used for surface cleaning [43].
Blood/body fluid spills should be cleaned with an EPA–registered germicide with specific claims for the elimination of HIV and Hepatitis B. If needed, an intermediate germicide that is tuberculocidal can be used. Spills of blood/body fluid should be removed as soon as possible. If there is a possibility of splatter, additional PPE should be worn by the HCW. Persons cleaning the OR should wear protective gloves [44].
Sodium hypochlorite (i.e., bleach) may be used for blood/body fluid spill cleanup. It should be a fresh solution of sodium hypochlorite in a 1:10 dilution (i.e., 1 part sodium hypochlorite to 10 parts water). When mixed, the solution should be dated and discarded after 24 hours [44]. HCWs should read the label contents on the sodium hypochlorite container to ensure that the product is not diluted and is the percentage needed [45].
Areas of the floor that are noticeably soiled need to be cleaned with a new or laundered mop head in an EPA–registered, hospital-grade germicide. A mop head that has been used should not be dipped in the clean germicide solution again. If the mop head is redipped into the clean solution, the solution must be discarded. Mopping the floor helps eliminate dust, debris, and soil. Following a surgical procedure, only a 3- to 4-ft perimeter surrounding the surgical field needs to be mopped. It is important to move the OR bed to ensure that the floor is not soiled and has nothing left under it. There is no scientific evidence to support cleaning the entire floor for SSI reduction.
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Terminal cleaning should be done once during every 24-hour period whether or not the OR has been used. This practice helps reduce resident microbial flora. Terminal cleaning includes the surgical lights and external tracks, ceiling-mounted equipment, all furniture and equipment (to include telephones and light switches), hallways and floors, handles on cabinets and push plates, ventilation faceplates, horizontal surfaces, substerile areas, scrub and utility areas, and scrub sinks. Soap dispensers that require refills are not recommended. Refilled soap dispensers can act as reservoirs for microorganisms [43].
Medical Waste
Contaminated items should be segregated into noninfectious and infectious waste. Waste that is contaminated with blood and/or tissue that would release blood/body fluids if compressed must be handled separately from other waste. Items that are infectious or could release blood should be placed in leak-proof, closable containers or bags that are color coded and tagged for easy identification as hazardous waste. Containers or bags are transported to a biohazardous waste area [43].
Medical waste is segregated into the following categories; laboratory and microbiology waste; bulk blood, blood products, and specimens containing blood and body fluids; pathology wastes (i.e., anatomical specimens); and sharps. Sharps should be disposed of in an impervious, puncture-proof container as near the patient care area as possible [44]. The perioperative area has one of the highest percutaneous injury rates of all practice areas, but perioperative staff are the least likely to report bloodborne pathogen exposures. Studies show that from 7% to 15% of all thoracic, trauma, burn, emergency orthopedic, major vascular, intra-abdominal, or gynecologic surgeries have sharps injuries incurred by the surgical team. Using the OSHA 300 Log or a Needlestick Injury Log will assist employees in determining the trends in injuries. This log also identifies the devices that are most often involved in exposures [46]. Personnel assigned to handle waste should be trained in the use of PPE and use it as needed. HCWs should use the same method for disposing of isolation waste as they would use with hazardous waste from the perioperative suite [44].
Operating Room Design and Environment
The OR design and its environment are very important in reducing SSI risk. A central core should be used for storing sterile equipment and supplies.
Heating, Ventilation, and Air Conditioning (HVAC)
The OR ventilation system should control the amount of particulates in the perioperative environment. Air is delivered from ceiling vents that should be located high on the walls of the room. The outlet exhaust vents should be located near the floor. These vents should be across from the inlet vents. The direction of incoming air should be downward with little flow of air toward the floor and exhaust outlets. The air pressure should be positive in the OR compared to the adjacent areas. This helps to decrease the amount of air moving into the OR from the adjacent areas [32]. There should be at least three outside air exchanges per hour in the total air exchange. This assists the exhaust requirements for the HVAC system. Portable air conditioners, humidifiers, or dehumidifiers should not be used in the perioperative area. These products may move air and microbes around, thereby increasing the possibility of an SSI [47].
Humidity levels should be controlled to decrease static electricity (i.e., a lower level of humidity increases the possibility of static electricity) and decrease the possibility of microbial growth (i.e., a higher level of humidity may increase microbial growth) [32]. Ideal ranges of temperature, levels of humidity, and number of air exchanges for perioperative areas are listed in Table 26-2.
Traffic Patterns in the Perioperative Suite
The number of HCWs present affects the level of microbes in the perioperative area; therefore, traffic should be
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minimized [13]. The surgical suite has three delineated traffic sections: unrestricted, semirestricted, and restricted.
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TABLE 26-2 |
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Movement into and out of the ORs should be kept to a minimum. Bacterial shedding increases with activity, and there may be more airborne contamination as a result of increased traffic. Talking and the number of people present during a surgical procedure should be limited [13].
Doors to individual ORs should remain closed except during the transporting of patients and the movement of staff, supplies, or equipment. This helps to maintain the appropriate number of air exchanges and levels of humidity.
Laminar Flow
The CDC suggests that healthcare facilities “consider performing orthopedic implant procedures in ORs supplied with ultra clean air” [13]. Laminar flow is listed as a category II recommendation, which means it is “suggested for implementation and supported by suggestive clinical or epidemiological studies or theoretical rationale” [13]. A study with 40 patients undergoing total hip replacement (THR) in an ultraclean and in a standard room was conducted. The objective was to use a molecular biological technique called polymerase chain reaction (PCR) to establish wound contamination rates after a THR in an ultra-clean and standard OR. The study covered a three-year period. Following skin incision, specimens of pericapsular tissue were obtained from each patient's posterior joint capsule. Surgeons obtained additional specimens at the end of the procedure and before closure. Gram stains and cultures were done immediately on one specimen. The other specimens were frozen for later PCR analysis. The results indicated that the ultra-clean rooms had no impact on the contamination rate at the start or end of the procedure. None of the specimens (n = 20) at the start of the procedure in the standard room was positive by culture; two were positive by PCR. At the end of the procedure, none of the specimens was positive by culture; six were positive by PCR. The findings in the standard OR specimens showed a higher contamination rate at the end of the procedure than at the start of the procedure. There were no specimens (n = 20) at the start of the procedures positive by culture done in the standard OR; three were positive by PCR. Two of the specimens taken at the end of the procedure were positive by culture, and nine were positive by PCR. Eight infections were detected by PCR in the cases done in the ultra-clean OR; no infections were detected by culture. The contamination rate for the standard and ultra-clean ORs were the same. The clinical implication is that greater effort should be taken in both types of ORs to control traffic and keep doors closed, especially at the end of the case [49,50].
Ultraviolet Light (UVL)
The premise for using UVL for low-level disinfection is that it kills select vegetative bacteria, fungi, and lipoprotein viruses on contact. It may, however, actually sustain life for other organisms. The usefulness of UVL is very restricted because the UV rays must to be in direct and close contact with the organisms. Some healthcare facilities have ORs with UVL installed; however, the UVL cannot be used when the OR is occupied. Care should be taken to wear protective clothing and goggles if entering a room when UVL is activated because it can cause skin burns, and conjunctivitis [51]. The CDC does not recommend the use of UVL as a method of decreasing SSIs (Category IB) [13].
Scrub Sinks
A scrub sink should be located next to each OR, or one sink can serve two ORs. There should be no scrub sinks in the central core to prevent splashes and aerosolization that could occur in an area where sterile supplies are kept [32].
Floors
Floors should be seamless, have a hard surface, be easy to clean, and have cove fittings from the floor to the wall. All of these measures prevent microbes from accumulating [32].
Sterilization of Instruments and Devices
Proper cleaning of instruments is critical for the sterilization process to be successful. Prior to transporting
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instruments to the decontamination area, an enzymatic solution, spray, or gel may be used on instruments that are difficult to clean. Instruments that can be should be opened/taken apart for thorough cleaning and removal of bioburden. If blood is allowed to remain on the instruments, corrosion and pitting may occur. A washer/sterilizer, ultrasonic cleaner, washer/decontaminator, or manual cleaning may be used for cleaning and decontaminating instruments. Personnel performing decontamination should wear PPE when working with contaminated instruments [52].
Prior to cleaning and decontamination, the following information needs to be determined:
Flash sterilization (steam sterilization using the unwrapped method) can be performed using a gravity or prevacuum steam sterilizer. This type of sterilizer is routinely available in the surgical suite to provide quick sterilization of devices when there is insufficient time to perform the preferred wrapped instrument methods. Operating room personnel should complete competencies in the operation of flash sterilization equipment prior to using this method.
To operate the sterilizer in the flash cycle, the following needs to be determined:
The use of flash sterilization containers may prevent contamination of the contents after completion of the flash cycle when transporting the container to the area needed. Flash sterilization containers present concerns including the requirement for special sterilization cycles, special biological testing, and various types of maintenance for the valves in the flash container.
Documentation of items processed in each flash cycle is recommended to track devices back to the patient. Flash sterilization of implants is not recommended. If an implant must be flash sterilized, the implant manufacturer's written instructions for cycle time and temperature must be followed. A biological test should be included in the cycle and the results documented.
Flash sterilization began as a means to quickly sterilize a single, one-of-a-kind device that was dropped or contaminated. Unfortunately, some facilities are using flash sterilization to compensate for inadequate instrument inventories, poor scheduling, and a lack of coordination/communication with vendors for loaner specialty instruments [53].
Surgical Instrument Tracking
Tracking surgical instrument use and finding their location have become very important. Missing instrument(s) require personnel time to find them, can be costly, and most importantly, may compromise patient safety [54]. Instrument sets can be identified by bar coding and can be scanned before and after they are decontaminated. Another system involves radio frequency identification (RFID) technology that uses a small tag that stores a code with information that the Sterile Processing Department (SPD) determines [55]. SPDs may also develop their own system. A digital camera may be used to photograph instruments. These photographs may be downloaded to a software system and be customized for the individual setting. Video demonstrations can then created if a multimedia feature is available [56].
The advantage of using a surgical instrument tracking system is that it allows the data collected every time the instrument(s) is moved to be recorded and the location noted. The software systems can generate reports and documentation on patient safety and protect healthcare facilities against litigation. If the SPD had a sterilization cycle in which sterilization parameters were not met, SPD is able to identify the location of the instrument(s) by utilizing a computerized tracking system. If a patient develops a postoperative infection, reports may also be used to track whether the instrument(s) were sterilized appropriately. A tracking system is only as good as the data that are entered. It is crucial to have well-trained personnel who understand the tracking process [54].
Scheduling Perioperative Procedures
Surgical procedures may be scheduled in the OR at any time with the exception of patients who have a latex allergy. If possible, it would be best to schedule a patient with a latex allergy as the first procedure of the day. Theoretically, as the day progresses, latex may be aerosolized from the supplies and gloves used. As the first procedure of the day, this risk is reduced as the air exchanges through the night filter out the latex [43].
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Disaster Management in the Perioperative Area
Perioperative personnel need to be prepared to respond to disasters. Since the terrorist attacks of September 11, 2001, in the United States, healthcare facilities have expanded their disaster preparation to include not only natural but also human made disasters. State and federal governments now mandate that all healthcare facilities have emergency response plans. The JC has stressed the importance of a plan that is scalable, sustainable, and community integrated. Healthcare facilities accredited by JC must conduct two tests of their emergency management plan in hospitals and one in ambulatory care facilities. This can be an actual emergency or a drill [57].
Conclusion
SSIs continue to increase as the number of at-risk patients requiring surgical interventions increases. Patients representative of this rise in at-risk population include the elderly, premature infants, and patients who are obese, immunocompromised, diabetic, or smoke. The length of hospital stay is decreasing, and an increasing number of invasive procedures are being performed in outpatient settings which include hospital outpatient, free-standing surgery centers, and office-based surgeries. The perioperative environment continues to be a hazardous one for patients and staff. HCWs who follow OSHA, CDC, AORN, APIC, ASA, and JC regulations/guidelines/recommendations can reduce the risk of pathogen transmission or injury to themselves and their patients, thus increasing the culture of safety in the perioperative environment.
References
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