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Breaches in the OR: The Perioperative and Infection Prevention Challenge


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Patient Skin Prep

Six percent of survey respondents said they had seen poor skin prep in the OR, or had noticed that the patient skin-prep solution had not been allowed to dry properly following application. Also, when it comes to the pre-surgical scrub issue, several respondents said they wanted to see a stronger stance on making products such as CHG-impregnated sponges available to OR staff.

"According to AORN’s Recommended Practices for Preoperative Patient Skin Antisepsis, only preoperative skin antiseptics that have been FDA-approved or cleared and approved by the healthcare organization’s infection prevention personnel should be used for preoperative skin preparation," Van Wicklin emphasizes. "The patient should be assessed for contraindications to specific skin preparation agents. Likewise, the patient’s skin condition should be assessed for the presence of lesions or other tissue conditions at the surgical site before skin preparation begins. The efficacy of antiseptic agents is dependent on the cleanliness of the skin. Preoperative washing removes gross contaminants and oils that may block penetration of the antiseptic agent and also removes spores and other organisms that are not killed by the antiseptic agent. Removal of superficial soil, debris, and transient microbes before applying antiseptic agents reduces the risk of wound contamination. Hand hygiene should be performed before initiating the prep. Sterile gloves should be worn unless the antiseptic prep applicator is of sufficient length to prevent the antiseptic and patient’s skin from contact with the non-sterile glove. The antiseptic agent should be applied to the skin over the surgical site and surrounding area progressing from the incision site to the periphery in a manner that minimizes contamination, preserves skin integrity, and prevents tissue damage. The prepared area should be large enough to accommodate potential shifting of the drape fenestration, extension of the incision, the potential for additional incisions, and all potential drain sites. Protective measures (e.g., occlusive drapes) should be implemented to prevent skin and tissue injury due to prolonged contact with skin prep agents. Solutions should not be allowed to drip or pool beneath or around the patient. The antiseptic agent should remain in place for the full time suggested by the manufacturer’s written recommendations. If a flammable solution is used, the agent should be allowed to dry and vapors to dissipate before application of drapes. The use of a flammable agent should be discussed during the time-out."


Holes in gloves and the improper use of gloves in general is still a vexing issue in the OR, with 5 percent of respondents reporting that personnel's gloves were somehow compromised -- whether through a puncture, hole or rip -- and healthcare workers were not changing their gloves when they should. Other respondents noted that OR staff members were wearing gloves for patient care and not removing them before touching items such as monitors, other equipment or phones in the room.

"According to AORN’s Recommended Practices for Prevention of Transmissible Infections, all members of the surgical team should double-glove during invasive procedures as this will minimize the risk of exposure to blood and the number of perforations to the innermost glove," Van Wicklin says. "Punctured or torn gloves should be changed immediately if a visible defect is noted or if contamination of the glove is suspected or has occurred. Likewise, appropriate actions should be taken to remove any instrument(s) or remedy any area of the sterile field that may have been compromised by contact with the unsterile glove. Gloves should be changed after contact with uncured methyl methacrylate because the wearer is at risk for direct contact and skin absorption of the chemical via penetration of the glove material. Gloves should also be changed when an unintentional electric shock from an ESU is received to the hands of the user; and, when gloves begin to swell, expand, and become loose on the wearer’s hands as a result of the material’s absorption of fluid and fats."

Surgeons and Anesthesiologists

Five percent of respondents were ready to point fingers at OR team members, especially surgeons and anesthesiologists, for breaches in practice in the OR. Many said that these physicians have a blatant disregard for the guidelines and ignore evidence-based practices relating to infection prevention and control. One respondent said she was growing weary of "surgeons who want try to short-change the proper protocol," while others said many surgeons and anesthesiologists were not wearing face masks or other items of PPE properly.


Surgical Instruments

More than 4 percent of respondents took issue with the lack of what they perceived to be proper cleaning, disinfection and processing of surgical instrumentation, both by the sterile processing department before the case opens, as well as instrument handling perioperatively. Respondents also noted a considerable lack of knowledge by some members of the OR team when it came time to use sterilizers properly, citing inconsistent sterile processing efforts.

Van Wicklin suggests that perioperative personnel consider that, "The term bioburden is frequently misused in the surgical setting because many consider this to be organic material on surgical instruments and equipment. According to AORN’s Recommended Practices for Sterilization in the Perioperative Practice Setting, the accurate definition of bioburden is, 'The degree of microbial load; the number of viable organisms contaminating an object."' A contaminated instrument may contain both organic material (e.g., blood, tissue, mucous, body fluids) and viable infectious organisms. Effective sterilization cannot take place without effective cleaning. The process of sterilization is negatively affected by the amount of bioburden and the number, type, and inherent resistance of microorganisms, on the items to be sterilized. Soils, oils, and other materials may shield microorganisms on items from contact with the sterilant, or combine with, and inactivate the sterilant. Therefore, if blood, bone or other suspicious material is found on an instrument, the entire tray should be considered contaminated with corrective measures taken immediately."

Flash Sterilization

With the aforementioned lack of knowledge about instrument decontamination and sterilization, it's no surprise that about 2 percent of respondents reported problems with autoclaving in the OR, whether it was done too frequently or at all.

Van Wicklin encourages perioperative personnel to use the correct verbiage to describe two distinct processes relating to sterilization int he OR. "The term 'flash sterilization' does not fully describe the shorter sterilization cycles currently in use to process instruments," Van Wicklin explains. "Likewise, it does not encompass the critical steps of cleaning, decontamination, and aseptic transport that must accompany any sterilization cycle. These processes in total are more accurately reflected and described by the words 'immediate-use steam sterilization.' Immediate-use steam sterilization should be kept to a minimum, performed in a controlled manner, and used only in selected clinical situations (eg, when there is insufficient time to process by the preferred wrapped or container method). All items should be subjected to the same decontamination processes as described in AORN’s "Recommended practices for cleaning and care of surgical instruments and powered equipment."

According to Van Wicklin, sterilization of items for immediate-use should be performed only if all of the following requirements are met:

- The device manufacturer’s written instructions on cycle type, exposure times, temperature settings, and drying times (if recommended) are available and adhered to.

- Items are disassembled, thoroughly cleaned with detergent and water to remove soil, blood, body fats, and other substances.

- Lumens are brushed and flushed under water with a cleaning solution and rinsed thoroughly.

- Items are placed in a closed sterilization container or tray, validated for immediate-use sterilization, in a manner that allows steam to contact all instrument surfaces.

- Measures are taken to prevent contamination during transfer to the sterile field.

- Sterilized items are used immediately and not stored for use at a later time.

"Immediate-use steam sterilization cycles should be monitored to verify that the parameters required for sterilization have been met," Van Wicklin adds. "Documentation of cycle information and monitoring results should be maintained in a log (electronic or manual) to provide tracking of the immediate-use sterilized item(s) to the individual patient."

Other Issues

There were a handful of other issues cited, with each issue representing about 1 percent of responses:

- Timely prophylactic antibiotic administration

- Compliance with SCIP measures

- Maintaining patient normothermia

- Holes in tray wrappers

- Moisture in instrument sets

- No sterility assurance of instruments

- Poor draping technique

- Proper barrier protection

- Proper handling of clean and sterile supplies

- Issues relating to humidity and temperature levels in the OR

- Safe injection practices, plus proper use of syringes and multi-dose vials

- Newspapers and magazines in the OR

- The condition and health of the patient coming into the OR

- Too much talking in the OR/inattention to the patient

- Staff not containing contaminated instruments while transporting to decontamination area

- OR personnel working when ill

OR Infections

With the many breaches seemingly occuring in the OR, respondents were not reporting sky-high infection rates. When asked if their OR has been associated with an infection or outbreak in the last six months, just 24 percent of respondents said yes, while 77 percent of respondents said no. But things got murkier when asked if respondents could identify the cause of an infection or outbreak. A few cavalier individuals attributed infection to the presence of "bugs" in the OR, while some said they were not provided with infection rate data. Eight-five percent of respondents said the cause was "unknown" or they were "unsure" about an infection's origins. About 5 percent of respondents blamed surgeons' practices for the infection, while another 5 percent identified improper skin antisepsis, inadequate patient prep, and improper draping. About 1 percent placed the blame on patients for their lack of compliance with pre-operative bathing or other measures, and another 1 percent pointed to patient co-morbidities. And about 3 percent of respondents blamed an infection on the "presence of staph bacteria."

Education, Education, Education

One critical area that needs improvement, survey respondents said, is the education of perioperative personnel. Not only must the level of education and training be elevated, it must be a continual process, they said. As one respondent put it, there must be a continuous effort on the part of perioperative and infection prevention educators to teach the concept of a "sterile conscience" to not only newbies, but to remind veterans of this obligation as well. One respondent advised, "Ensure proper initial instruction on all procedures and constant reiteration," while another advocated "frequent education of all staff and contracted personnel on infection prevention and control." The continual education process is necessary, said one respondent, due to "turnover that increases the likelihood for forgotten or ignored protocols among staff."

Collaboration Between IPs and Perioperative Personnel

Collaboration between perioperative professionals and infection preventionists seems to be a given among survey respondents; 79 percent of perioperative personnel indicated they worked closely with their institution's infection prevention department to help control and eliminate potential for infections. Eleven percent admitted that they "sometimes" work with infection prevention, while 5 percent said they "never" worked with this department. Noted one respondent, "I am the IP, and the OR director and I have a very strong working relationship with mutual respect for each other's knowledge base." But not everyone had this kind of relationship; one respondent noted, "I am the IP, and the OR nurse manager undermines input from infection prevention, including policies." A few other respondents reported that not only did they collaborate with the infection prevention department, but they also included the sterile processing department in their conversations.

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