To access a slide show based on this March 2011 ICT cover story, CLICK HERE.
By Kelly M. Pyrek
Last year, we surveyed professionals working in surgical services and perioperative nursing and infection prevention about how well recommended practices are being implemented in the surgical suites across the U.S. When asked what they believed was the most critical component of infection prevention and control in the OR, 76 percent cited maintaining the sterile field; 57 percent cited proper patient skin prep; 55 percent cited proper surgical scrub/hand antisepsis; 43 percent cited proper barrier protection; and 28 percent cited other concerns.
One year later, the story remains the same, essentially, with a few tiny shifts in perception of priorities. When asked what they thought was the most critical component, 66 percent cited maintaining the sterile field; 61 percent cited surgical scrub/hand antisepsis; 53 percent cited patient skin prep; 30 percent cited proper barrier protection, and 23 percent pointed to other concerns that will be discussed in this article.
A savvy respondent summed it up by saying that a "sterile conscience" was most critical, "because if an individual has that, all things mentioned above will be covered completely," while another respondent emphasized, "I don't feel one of these are more weighted than the next in steps of prevention. They are ALL necessary steps to create an environment of the highest standards to prevent infection."
Hand Hygiene
Lack of or improper hand hygiene was the No. 1 breach reported in the 2011 survey, with 25 percent of respondents consistently reporting a failure by OR personnel to engage in timely, proper hand disinfection, especially after removing gloves.
The importance of proper hand hygiene cannot be overemphasized as this is the single most important measure to reduce the spread of microorganisms," says Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC, a perioperative nursing specialist with the Association of periOperative Registered Nurses (AORN). "Proper hand hygiene protects both patients and health care workers from exposure to blood, body fluids, microorganisms and other hazardous substances."
Van Wicklin reminds practitioners that hand hygiene should be performed:
- upon arrival at the healthcare facility
- before and after every patient contact
- before putting gloves on and after removing gloves or other protective equipment
- any time there is a possibility that there has been contact with blood or other surfaces
- before and after eating
- before and after using the restroom
- before leaving the healthcare facility
- when hands are visibly soiled
"According to AORN’s Recommended Practices for Hand Hygiene, a surgical hand scrub should be performed by all members of the surgical team before donning sterile gown and gloves," Van Wicklin says. "Although the skin can never be rendered sterile, it can be made surgically clean by reducing the number of microorganisms. The surgical hand scrub should be accomplished according to the manufacturer’s written directions for use using either an antimicrobial surgical scrub agent intended for this purpose, or an alcohol-based antiseptic surgical hand rub with persistent and cumulative activity that has met the FDA requirements for surgical hand antisepsis. Surgical hand antisepsis/handscrubs are effective only if all surfaces are exposed to the mechanical cleaning and chemical antisepsis process. Surgical hand hygiene products should be selected, evaluated and approved by the organization’s infection prevention personnel."
Surgical Attire
Eighteen percent of survey respondents cited problems relating to surgical attire as the most common breach seen in the OR, and it was the second most-cited issue by survey respondents. Specifically, respondents noted these situations:
- Wearing inappropriate attire
- Improper use of surgical attire
- Bringing personal items into the OR such as handbags, briefcases and laptops
- Wearing home-laundered surgical attire, especially caps
- Staff coming and going with shoe and head covers without replacing them before returning to the OR
- Lack of proper head coverings
- Hair not covered or contained
- Staff wearing long sleeves underneath scrubs
- Surgeons not changing into hospital-laundered scrubs
- Improper wearing of masks
- Improper fit of masks and head gear
- Lack of protective eyewear
- Staff wearing jewelry
- Reps walking into the OR without donning OR attire
Although it has always recommended institution laundering of surgical attire, the Association of periOperative Registered Nurses (AORN) is unequivocal on this position in its newly revised Recommended Practices for Surgical Attire, released in December. In this recommended practice, AORN is underscoring the science-based rationale for quality assurance monitoring of laundering practices, as well as taking a stand on other attire-related issues that compromise patient safety. AORN recommends that surgical attire should be laundered in a healthcare-accredited laundry facility, according to Recommendation V within the recommended practice, and all recommendations for home laundering of surgical attire have been removed. This is the most significant change since 2005, when the Recommended Practices for Surgical Attire was first released. Like other recommendations in this updated recommended practice, Recommendation V includes an expanded rationale section that cites literature and guidelines published since the previous version.
In addition to the new recommendation on quality assurance monitoring of laundering processes, the updated recommended practice on surgical attire includes:
- New information on characteristics of safe surgical attire fabrics, including recommendations that fabrics should be tightly woven, stain resistant and durable, and that 100 percent cotton fleece should not be worn
- Recommendations for safe footwear
- More information on wearing of jewelry, including how, where and when jewelry can be worn
- New information on regular and appropriate cleaning of stethoscopes and ID badges
- A new recommendation that fanny packs, brief cases and backpacks should not be taken into semi-restricted or restricted areas
- Updated information on disposable and reusable head coverings
Breach of the Sterile Field
The third most cited issue in the OR was breach of the sterile field, with 17 percent of respondents saying they had witnessed actions taken by OR personnel that compromised the integrity of this highly restrictive area. Specifically, respondents noted these situations:
- Non-scrubbed personnel reaching across the sterile field
- Inadvertent contamination of the OR table
- Personnel turning their backs to the sterile field
- Hands below the OR table level
Of note, several respondents acknowledged the presence of technology-driven equipment that further challenged the constant protection of the sterile field.
"Adherence to aseptic practices by all individuals involved in surgical and invasive procedures helps to fulfill the responsibility of perioperative team members to reduce the risk for surgical site infection and to protect the patient from injury," Van Wicklin says. "Healthcare-acquired surgical infections are a leading cause of patient morbidity and mortality in the United States. According to AORN’s Recommended Practices for Maintaining a Sterile Field, rigorous adherence to the principles of asepsis is the foundation of surgical site infection prevention and should never be circumvented to save time or money. The surgical team should utilize proper aseptic technique for all surgical patients and all invasive surgical procedures should be performed using sterile instruments and supplies. When a break in sterile technique occurs, corrective action should be taken immediately unless the patient’s safety is at risk. If the patient’s safety is at risk, the break in technique should be corrected as soon as it is safe to do so."
Van Wicklin continues, "Personnel should be knowledgeable about the procedures involved in developing and maintaining a sterile field. An introduction and review of policies and procedures for maintaining the sterile field should be included in orientation to the perioperative setting for all personnel. Continuing education should be provided when new technologies are introduced. Ongoing education of perioperative personnel facilitates the development of knowledge, skills, and attitudes that affect aseptic practices and surgical patient outcomes.
Traffic Control
In both the 2010 and 2011 ICT surveys, traffic in the OR has been a consistent concern, as one survey respondent noted, "I would like to see more investigation on the limitation of the number of people in the OR suite. With the increased number of students, residents, etc, this is creating an unsafe environment with a high number of people in the OR. The number of reps in OR suites needs to be reduced." This fourth most common breach was identified by 13 percent of respondents who reported they too had a high volume of traffic going in and out of the ORs, and that appropriate traffic control was sorely lacking. Many respondents complained about personnel leaving the OR doors open, or leaving the OR open while unattended.
"According to AORN’s Recommended Practices for Traffic Patterns, movement of personnel should be kept to a minimum while invasive and noninvasive procedures are in progress," says Van Wicklin. "In order to maintain critical environmental parameters such as a minimum of 15 total room air exchanges per hour, doors to the operating or procedure rooms should be closed except during necessary movement of patients, personnel, supplies, and equipment. Air is a potential source of microorganisms that can contaminate surgical wounds. Microbial shedding increases with activity and greater amounts of airborne contamination can be expected with increased numbers and movement of surgical team members. As well, operating rooms must be secure. Patient privacy must be maintained, patient, personnel and visitor safety should be ensured, and supplies and equipment should be protected from tampering and theft."
Break in Sterile Technique
Coming in as the fifth most common breach in the OR is a lack of or break in sterile technique, with 8 percent of respondents saying they noticed improper practices that could lead to infection or post-surgical complications.
Environmental Hygiene in the OR
Six percent of respondents felt strongly that timely and proper cleaning and disinfection of the surgical suite was not occurring, whether it was between cases or terminal cleaning at the end of the day. One respondent cited a "deplorable lack of adequate cleaning of high-touch areas between cases as well as the lack of cleaning of equipment," while another respondent said "the OR team is pressured for a quick OR turnover and are not waiting an appropriate time before opening the next case."
"Environmental cleaning is a team effort involving surgical personnel and environmental services personnel," Van Wicklin emphasizes. "All areas and equipment in the surgical practice setting should be cleaned according to an established schedule. Routine cleaning and disinfection reduces the amount of dust, organic debris, and microbial load in the environment. Following scientifically based recommendations for cleaning and disinfection practices in healthcare organizations helps to reduce infections associated with contaminated items."
Van Wicklin points to AORN’s Recommended Practices for Environmental Cleaning in the Perioperative Setting that says all horizontal surfaces in the OR (e.g., furniture, surgical lights, booms, equipment) should be damp-dusted before the first scheduled surgical procedure of the day. "Cleaning and disinfection methods that produce mist, aerosols, or dust (e.g., spray bottles containing disinfectant) should not be used," she says. "Manufacturers’ cleaning recommendations should be consulted before cleaning computer keyboards, monitor screens, telephones, and other electronic devices. Equipment from areas outside the restricted area of the OR should be cleaned before being brought into an OR. Surgical and invasive procedure rooms and scrub/utility areas should be terminally cleaned daily. Terminal cleaning and disinfection of the perioperative environment decreases the number of pathogens, dust, and debris that is created during the day. Terminal cleaning and disinfection of operating and invasive procedure rooms should be done when the scheduled procedures are completed for the day, and each 24-hour period during the regular work week. Unused rooms should be cleaned once during each 24-hour period during the regularly scheduled work week. All personnel must comply with OSHA’s bloodborne pathogen standards when performing cleaning and disinfection procedures involving contact with blood and other potentially infectious materials."
