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Breaks in Aseptic Technique Require Review of OR Basics

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Surgical Attire

One of the most critical elements of aseptic technique is wearing the appropriate kind of surgical attire that provides impervious barrier protection against exposure to potentially infectious body fluids and tissue during invasive surgical procedures. Such attire – called personal protective equipment (PPE) — consists of caps, face shields and surgical masks, surgical gowns and gloves and sturdy, closed footwear. To protect the patient from microbial contamination, sterile drapes are applied to the incision site.

“One of the most important practices related to PPE use in the OR is the implementation of Association for the Advancement of Medical Instrumentation (AAMI) guidelines,” says Wava Truscott, PhD, MBA, director of scientific affairs and clinical education for Kimberly-Clark Health Care. “Ultimately, these guidelines help users understand the level of protection needed when selecting PPE for both isolation and surgical gowns as well as surgical drapes for various procedures. There are five designated levels of performance: AAMI Levels 1-4 represent increasing protection against greater fluid volumes subjected to higher pressure challenges; and non-protective designation, for gowns that fail to meet the Level 1 category requirements.” Truscott adds, “It is important to work closely with the gown selection committees and materials managers to ensure that selections are made in full knowledge of the exposure risk and gown performance requirements needed. Use AAMI PB70 to enable credible comparisons of gown fluid resistance performance. Acquire data on aerosol and dry spore barrier performance. After appropriate levels of protection are procured, facilitate compliance by storing gowns such that they are readily accessible in/near areas where need for that level of protection is anticipated. Reduce healthcare worker and environmental contamination by posting proper PPE removal techniques, providing convenient disposal bins and appropriately placed hand sanitation stations. Address both concern categories: noncompliance and assumed protection. Enable staff and patient protection.”

ICT survey respondents said they observed many instances of improper barrier protection, with specific problems including the movement of drapes after application, contamination when draping, barrier breakthrough, glove punctures and gown strike-through. “I see constant glove tears, rips and punctures,” said one survey respondent, who added, “What bothers me is the poor re-gloving technique.” Another survey respondent noted, “Improper wearing of face masks is a big problem” while others cited hair hanging outside of hats and shedding into wounds from errant hair or improper attire. One respondent observed, “Lack of compliance to the facility’s dress code for the OR is a big problem,” while another person said, “I see disposable masks being used all day and left hanging around the neck when not in use.” Yet another person commented, “Surgeons wear the same scrubs they were in when they came from another hospital.”

Many members of the surgical team may experience a breach of their gloves intraoperatively. “Breach of surgical gloves occurs frequently,” says Carolyn L. Twomey, RN, BSN, global head of clinical services for Molnlycke Health Care US, LLC. “Incidences from the literature are often as high as 11 percent to 51 percent, depending on the complexity of the case, the prevalence of bone fragments, the instrumentation and use of and management of sharps in the field, and certainly the expertise and technique of the practitioner. For medical students needlesticks occur frequently, as high as 59 percent of the time. And these are only the reported needlesticks. Another study reports only 17 percent of the practitioners in the U.S. report needlesticks. Often practitioners do not know the have a breach until they finish the case and remove their gloves to find blood on their hands.” Twomey continues, “Double-gloving is now recommended as a risk reduction strategy by many organizations, including AORN in its Recommended Practices, the American College of Surgeons, The American Association of Orthopaedic Surgeons and others. Double-gloving exponentially reduces that risk. The use of a colored puncture indication system provides a visual alert to the wearer that they have a glove compromise and allows them to change their glove(s). Best practice recommends changing of both inner and outer glove in the event of a needlestick.”

Perhaps one of the biggest issues today focuses on scrubs – both the wearing of scrubs in and out of the OR, and the debate over proper laundering of this kind of attire. “I constantly see the wearing of surgical scrubs outside of restricted areas and coming back into the OR,” one ICT survey respondent noted, echoing a vast majority of respondents’ experiences. And as one person noted, “The issue of hospital-laundered versus home-laundered scrubs has got to be resolved.”

“We have our scrubs laundered in-house,” says McNamara. “There are a few exceptions for people with allergy issues and they have specific instructions to follow, including containing their scrubs when carried in or out of the facility, as well as washing instructions for home laundering. But overall, our personnel are not allowed to wear their scrubs in or out of the facility, and we police this very carefully. If staff are caught breaking this policy, we address it, and so far we had very good luck with compliance. We had to explain to people about the ‘germiness’ of their scrubs and the studies that have shown the persistence of microorganisms on cloth. I also tell people, besides what you might bring into the facility on your scrubs, think about what is on your scrubs at the end of the day that you are taking home to your family. Education is key and you have to follow up on issues like these. If you have someone not doing what they should, you have to find out if they are simply not educated about it – is our process not in place where we can support them in doing the right thing? Or are they just blatantly not following policy?”

ICT survey respondents also noted that OR personnel are bringing into the surgical suites numerous items from the outside world, including newspapers, purses, tote bags and laptops. Bringing food and drink into the OR was also noted by many survey respondents, including one nurse who said the anesthesiologist was “always hiding food in drawers.”

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