Nursing Role

Microsurgery Team's Role in Surgical Site Infection Prevention


Team strategies for assessing and preparing the patient and the OR

By Cynthia Halvorson, RN, MSN, CNOR

Approximately 27 million surgical procedures are performed each year. As the third most-reported nosocomial infection, surgical site infections (SSIs) account for 14-16% of nosocomial infections.1 A 1992 study estimates that SSIs increase the hospital length of stay by seven additional admission days and add an extra $3,100 in charges per admission (for tissue debridement, antibiotic therapy, and other treatments). 1

Implications

Put into the context of today's healthcare reality of managed care, case management, and clinical pathways, this is neither an acceptable clinical or financial outcome for surgical patients. The objective of case management is to provide "a continuum of care that allows consistent delivery of quality treatment and services across all care continuums."3 Case management focuses on patient populations that are complex (but not necessarily acute) with multiple interacting issues in addition to being high risk, high volume, or requiring high utilization of services. Within case management clinical care, paths are used as "guidelines that outline the ideal course of treatment during the episode of care"4 and are designed to decrease costs, improve outcomes, and increase patient satisfaction.5 Today's healthcare is measured in outcomes of cost and satisfaction. Surgical site infection rates are an important indicator of these parameters.

Microsurgery Patient Population

Patients undergoing microsurgical procedures are appropriate for case management pathways. Microsurgical procedures are performed in several surgical subspecialties. These are complex, technically precise, and challenging procedures. The length of stay ranges from a three-hour outpatient admission for the cataract patient to an AM admission and a five-day postoperative length of stay for the acoustic neuroma patient. Cataract patient volume is high (an average of 10+ patients/surgeon/day) while the acoustic neuroma patient has high risk and requires multidisciplinary services. In addition, Centers for Disease Control and Prevention (CDC) lists the likely SSI pathogens for several microsurgery procedures as well as site-specific organ/space SSI (disc space, mastoid space, endophthalmitis).6

Nursing Role

The nursing profession describes its primary role as patient advocacy. Central to this advocacy role is the goal of ensuring patient safety. This is especially true for perioperative nursing and the surgical patient. During the perioperative surgical experience, the patient receives a rapid sequence of care from a multidisciplinary team within a shortened length of stay.

The patient's most vulnerable phase of care is in the operating room. The patient has a dependent trust on his providers because of positioning requirements, anesthesia (general, monitored anesthesia care or conscious sedation), and inherent to surgery, the compromise of the first line of defense against infection. The two most frequent critical judgments and clinical decisions of perioperative patient care are protecting the patient from harm and injury (from surgical positioning requirements, use of electrosurgical, and laser units, etc.) and preventing surgical site infections.7

Infection Control Practices

The prevention of surgical site infections is not a result of isolated actions taken by one provider. Rather, it is the objective and desired outcome of an integrated team process. The process of infection control includes a variety of strategies and techniques across the continuum of perioperative care, including the pre-operative, intra-operative, and post-operative phases. Many advances have been made in infection control practices, addressing aseptic and surgical techniques as well as antimicrobial prophylaxis. In particular, the Association of periOperative Nurses (AORN) Recommended Practices serve as guidelines for clinical practice for the microsurgical team. These guidelines are based on microbiology, research, review of evidence-based literature, and opinions of multidisciplinary experts.8 The Recommended Practices with infection prevention application can be grouped into the sterilization process; patient preparation; the environment, and the sterile field (Table 1).

Microsurgery Technique

Several surgical specialties include microsurgical procedures. The knowledge and skills basic to general operating room care are applied to these microsurgical procedures, taking into account the specific considerations and needs of the subspecialty. Ophthalmology, orthopedics, ENT (including otology and laryngology), neurosurgery, and reconstructive plastics are specialties with microsurgery procedures (Table 2).

Microsurgery requires optical magnification, using an operating microscope to visualize anatomical structures not adequately visible to the unaided eye.9 As the optical magnification increases, the scope of field and depth of focus decreases, increasing the illumination requirements. As compared to major abdominal procedures (such as organ transplant or colon rectal procedures) the operative field area is just millimeters to centimeters in size. In addition, the room is darkened to enhance the high intensity illumination of the microscope's light source. The surgeon does not take his eyes from the microscope to receive instruments -- the scrub person hands the instruments to the surgeon in the position of use. By taking his eyes from the microscopes, the surgeon's concentration is broken, requiring refocusing on the surgical field through the microscope and can increase the length of surgery.

Surgical Instrumentation

To perform these delicate, precise procedures, special instruments are used. Theses include a variety of instruments in the same categories as general instrumentation, i.e., sharps and cutting items (scissors, scalpels, knives), graspers (clamps, forceps), and retractors (self-retaining, hand-held) that are designed to fit the specific technical needs of the procedure and micro-anatomy. The instruments are made of either non-corrosive stainless steel or titanium. All microsurgery instruments are delicate and expensive but with proper care and handling, can withstand multiple processing for several years.

The decontamination and processing of these instruments is dictated by their design. Delicate instruments must be separated from heavier general instruments. Hand washing is necessary for instruments that cannot tolerate the powerful cycle of the washer-decontamination unit or items that cannot be immersed (such as air-powered drills, hand-held lens, ultrasonic irrigation, and aspiration handpieces).

Technology

Optimal surgical exposure is key to any procedure. Many microsurgical procedures require exposure through bony structures (vertebral discs, temporal, or mastoid bone) using high-speed air powered drills. Components of these drill systems include a motor cord, motor handpiece, attachments, and drill bits. Further soft tissue dissection or evacuation is accomplished with lasers, using either a free beam (such as CO2 laser for microlaryngoscopy) or a laser fiber (such as argon laser for otology, acoustic neuromas, vitreo-retinal procedures, or brain tumors), or an ultrasonic suction-irrigation-aspirator (phacoemulsification unit for cataract extraction or the CUSA unit for neurosurgery).

Implants and Grafts

Many microsurgery procedures involve the placement of an implant or a graft. CDC identifies such procedures as at risk for SSI, requiring preoperative prophylactic antibiotics. Implant material varies from metals (stainless steel, MRI-compatible titanium), metal-plastic combinations, plastics, silicones (as formed implants or as injectable oil), and acrylics. Graft material can be autologous (patient's own tissue) or donor tissue (corneal transplants or processed donor tissue such as bone). These implants are supplied sterile and do not require sterilization within the institution. Documentation of implants and grafts on the operative record identifies the implant, manufacturer, lot and serial number, implant size, location and expiration date. An implant documentation record identifying the implant, patient, implanting surgeon, institution, and date of implant is returned to the manufacturer. The surgeon and patient can then be notified in the event of a product alert or recall.

Length and Phases of Cases

The length of surgery, complexity, and phases of microsurgery procedures and the number of team members involved vary greatly. Operative times for myringotomies and cataracts are 5 and 10 minutes respectively, while an acoustic neuroma is 6 to12 hours in length. Less complex procedures require only four personnel (anesthesia, scrub, circulator, and surgeon) while multi-specialty procedures can involve as many as 12 personnel. Many procedures require 30 to 60 minutes of setup time to prepare the sterile field, set up and test equipment, and safely position the patient for extended procedure time. More complex procedures involve two or more specialties with several surgeons, residents, and fellows. Crossed-trained OR teams work together throughout the procedure. Additional non-scrubbed members include anesthesia providers and neuro-diagnostic personnel for intraoperative monitoring.

During these longer procedures, the OR nurses "stage" activities to the progressive phases of the procedure. This is necessary to ensure smooth flow of the procedure with multiple team members (scrubbed and not scrubbed) and availability of required instruments, equipment, and supplies. Equipment needed later into the procedure is set-up and opened closer to point-of-use to keep the sterile field and operating room less cluttered and to decrease the likelihood of contamination from an extended exposure time.

Team Strategies for Infection Prevention in Microsurgery

The perioperative nurse is in an excellent position as the primary patient advocate to guide the patient's surgical experience and ensure appropriate infection prevention practices are implemented. When preparing for new procedures, the RN specialty manager meets with the surgeon to discuss key aspects of the procedure. A detailed preference/procedure card (i.e., standing orders for specific procedure) is written to include instrumentation, equipment, supplies, and medications. The entire OR team meets with the surgeon, anesthesia-providers, and other team members for an oral review of the procedure and conducts "dry labs" to prepare before a "live" case.

Assessment of Risk Factors

The perioperative nurse must be knowledgeable of the SSI risk factors, create and maintain a safe, effective environment, and classify the surgical wound. A complete assessment of the patient and surgical procedure is necessary. Table 3 lists the patient (intrinsic) and operative (extrinsic) risk factors. The patient's medical status is expressed as the American Society of Anesthesiologists physical classification system (ASA physical status). The anesthesia provider scores the patient as a preoperative predictor of the patient's risk for surgery. This status is also considered predictive for SSI. Healthier patients scored one or two (healthy or mild systemic disease) and are at lower risk than sicker patients with chronic and/or poorly managed diseases (scored 3 or 4). The surgical wound is classified in the OR at the conclusion of the procedure according to CDC criteria (clean, clean-contaminated, contaminated, and dirty-infected). Most microsurgical procedures are Class I, clean. The surgeon and circulating RN base this on the type of surgery, condition of the wound, and maintenance of aseptic technique throughout the procedure.

Table 1: AORN Recommended Practices with Infection Control and Surgical Site Prevention Guidelines

A. Sterilization Process

  1. High Level Disinfection
  2. Care & Handling of Instruments & Powered Equipment
  3. Selection & Use of Packaging Systems
  4. Sterilization in the Practice Setting

B. Patient Preparation

  1. Skin Preparation of Patients

C. Environment

  1. Anesthesia Equipment, Cleaning & Processing
  2. Surgical Attire
  3. Environmental Cleaning in the Surgical Practice Setting
  4. Traffic Patterns in the Perioperative Setting
  5. Standard and Transmission Based Precautions

D. Sterile Field

  1. Use & Selection of Barrier Materials, Gowns & Drapes
  2. Surgical Hand Scrubs
  3. Maintaining the Sterile Field

From Standards, Recommended Practices, and Guidelines. Association of Operating Room Nurses; Denver, CO: 2000.

Patient Preparation

Microsurgery exaggerates several risk factors. Patients undergoing complex procedures (neurosurgery) are admitted the day of surgery (DOS) in the morning to reduce preoperative length of stay. Many microsurgery procedures are long (over two hours) and involve the placement of an implant or graft. CDC includes these two factors in a higher risk group and ranks prophylactic preoperative antibiotics (PPA) as Category 1A.10

Preoperative Prophylactic Antibiotics (PPA)

PPA is an accepted standard of care for SSI prevention. Antibiotics are administered to reduce the microorganism burden to a level that does not exceed the patient's natural defenses. To be effective, administration is timed to ensure adequate serum and tissue concentration before the incision is made and to maintain the level throughout the procedure.11 Typically, the antibiotic is administered intravenously in the holding area 30 minutes prior to the patient entering the operating room. Often these cases are longer than the agent's three-to-four hour effective concentration level, necessitating intraoperative redosing (such as nafcillin at 6 hours for acoustic neuromas). Antibiotics are also given intra-operatively on the sterile field in an irrigation solution (such as cefazolin or bacitracin in normal saline for orthopedic, neuro/neurotology, plastics procedures), topical ointments or drops (for otologic and ophthalmic procedures) or injection (gentamycin or cefazolin subconjunctival injection for vitreo retinal and trabeculectomies, respectively). The perioperative nurse must know the likely SSI source pathogen risks for the various microsurgery procedures, the patient's allergies, and ensure the antibiotic of choice is available and administered appropriately. Lewis and Porazzi apply the Five R's of medication administration to PPA (Table 4).12

Table 2: Surgical Specialties with Microsurgery Procedures

ENT

Otology:

Ossicular chain procedures * (stapedectomy, ossiculoplasty)
Chronic ear procedures (tympano-mastoidectomy)
Myringotomy w/ventilation tube insertion *
Sensorineural hearing loss procedures * (Cochlear implant)

Laryngology:

Microlaryngoscopy

Neurotology:

Acoustic Neuroma
Vestibular neurectomy

OPHTHALMOLOGY
  Anterior Procedures:

Cataract extraction w/IOL *
Corneal transplant *
Glaucoma procedures * (trabeculectomy, valve placement)
Vitreo-retinal Procedures:
Vitrectomies *

ORTHOPEDICS
  Ortho Spine:

Micro discectomy

NEUROSURGERY

Craniotomy

RECONSTRUCTIVE PLASTICS

Micro re-vascularization of tissue flaps

  • Indicates procedures involving implant or graft placement

Patient Attire

Preparation of the patient also includes patient attire and the shave-and-skin prep. Just as the surgical team wears surgical attire (scrubs, hats, masks), the patient wears a hospital gown and hair covering. The exception to this rule is outpatient procedures, such as cataract extraction. Many centers require at most disrobing to the waist only and may require simply a patient gown over the patient's street clothes. Pathway data supports this protocol. The total admission time for the patient is shortened, and post-operative complications (i.e. endophthalmitis) have not increased.

Skin Preparation

Hair removal is the first step in skin preparation. The shave prep is done as close to the time of surgery as possible. Considering the body areas of microsurgery (spine and head), this is done in the OR after induction and positioning. Endophthalmitis is attributed to endogenous sources, particularly from the eyelashes, which harbor microorganisms. The eyelashes are clipped for vitreo retinal procedures using a curved iris scissors with blades coated with an ophthalmic antibiotic ointment to catch the lashes. Vitreoretinal procedures are similar to endoscopy procedures (such as arthroscopy), involving infusion and aspiration lines and portals for operative instruments. These lines could potentially drag pathogens into the vitreous chamber.

The scrub prep follows general skin preps. Neurosurgical preps add an alcohol step for degreasing. Eye preps include irrigating the eye with sterile saline, cleansing the base of the eyelashes and the periorbital area with a betadine solution.

The Environment

Preparing the surgical environment involves many steps, several of which are completed the day prior to the patient's scheduled procedure. Equipment, such as microscopes, are covered during storage to prevent dust accumulation on its surfaces. Terminal cleaning is done at the end of the day's schedule on all horizontal surfaces, surgical lights, furniture, equipment, ventilation plates, anesthesia equipment, and contact surfaces (handles, switch plates, etc). Prior to the first case of the day, damp dusting is done on horizontal surfaces and overhead surgical lights. The perioperative nurse does a quick visual check of the room before set up and opening of sterile supplies.

Extraneous traffic through the room by personnel not involved in the case is discouraged. Since the microsurgery room is often crowded with multiple pieces of equipment and the team is busy with tasks, contamination may not be observed. During the case, strict adherence to aseptic technique is critical. Contamination is event related and with longer cases, there is more opportunity for an event to occur. This can be challenging because many microsurgical procedures are performed in a darkened room to enhance the illumination of the surgical anatomy by the microscope's light source. Many teams "map" out the procedure room set-up for optimal placement of equipment, furniture, anesthesia, and team members. This allows the scrub team easy access to instruments and equipment, the anesthesia providers' patient access for monitoring, and the non-scrubbed team to circulate in the room without compromising the sterile field.

Traffic patterns and zones are established to reduce cross contamination, control access to the areas, and to facilitate efficiency.13 These divisions separate the department by activity and required attire. In the unrestricted area, there is interfacing with other departments (such as the scheduling department and holding area) and street clothes are allowed. The semi-restricted area includes sterile storage, instrument processing, and access corridors, which require scrub attire to be worn (scrubs and hats). In restricted areas of sterile cores, autoclave usage, and ORs with open sterile supplies or a case in progress, masks must be worn. All members of the microsurgical team, scrubbed and non-scrubbed, must observe these requirements.

Three parameters of the OR environment are controlled to inhibit the growth of microorganisms. Humidity is maintained at 30-60%, the rooms are kept cooler at 68-73ºF, and the room is ventilated through high-efficiency filters at a rate of 20-25 total room air exchanges per hour.

Instrumentation must be delivered to the OR sterile and in proper working condition. When creating instrument sets and single items, the service specialty manager works with the CS team to select the best packaging system (rigid container, peel pac, protective tray and tips) as well as decontamination and sterilization methods (steam, gas, or plasma) using the manufacturers' guidelines. Some items required special detail in processing. Drills and irrigation/aspiration handpieces have components that must be separated for cleaning and safety seals that are replaced. Inservice training and initial support by the vendor for both the OR and CS team is important. The CS team provides support intra-operatively when a contaminated item or additional items are needed as well as processing the instrumentation during the turnover between cases.

The sterile field is defined by the surgical draping of the patient, equipment, and furniture. Patient draping isolates the surgical incision area. Equipment used in the sterile field or brought into proximity must be draped. Microscopes are brought in close to the field with the ocular arm extended directly over the field. Draping allows the scrubbed personnel to adjust the microscope, protects the field from contaminants on the surface of the microscope and provides a sterile backsplash during drilling. Drapes are selected according to the particular needs of the case. Towels and/or adhesive drapes are used to "square off" or outline the prepped incisional area and to confine hair. Adhesive incise drapes are used for ophthalmology procedures that do not require eyelash clipping (cataracts) to confine the eyelashes. Disposable drape technology provides extended barrier properties against moist bacterial "strike through" and control of blood and body fluids and irrigation during the procedure.

Table 3: Assessment of Risk Factors for Surgical Site Infection

A. Patient Factors (Intrinsic)

  • age
  • nutritional status
  • medical status (i.e., ASA score) (HTN, diabetes, respiratory)
  • tobacco use
  • weight
  • co-existent infection at remote site
  • microbial colonization
  • compromised immunity
  • preoperative length of stay
  • allergies

B. Surgical Factors (Extrinsic)

  • duration of surgical scrub
  • skin antisepsis
  • pre-operative shaving
  • pre-operative skin prep
  • duration of operation
  • antibiotic prophylaxis
  • OR room ventilation
  • sterilization of instruments
  • surgical drains
  • surgical technique
  • placement of graft or implant
  • OR environment (temperature; humidity, traffic, sanitation)

*Adapted from Guidelines for Prevention of Surgical Site Infection, 1999 CDC: Atlanta, GA.

Conclusion

The perioperative nurse can use optimal aseptic technique for case set up and throughout the procedure. However, providing a safe and effective microsurgical experience for the patient begins before the day of surgery. SSI prevention is a collaborative and integrated process involving many departments as well as professional, technical, and support personnel. The multi-skilled support staff prepares a surgically clean environment and provides sterile instrumentation. The pharmacist and holding-area RN ensure administration of the preoperative prophylactic antibiotic. Equipment vendors provide inservice training and processing technical support to the CS and OR team. All personnel involved directly in the case observe traffic and attire protocols as well as correct any sterile field compromises.

The perioperative nurse is in an excellent position to ensure an effective pathway. The nurse combines knowledge of the procedure, potential pathogen contaminates, and appropriate prophylactic antibiotic agents with a complete patient assessment to prepare for the case. Intraoperatively, additional instruments and equipment are available and readied for point-of-use. The sterile field and OR environment are monitored throughout the procedure. With assistance from the housekeeping and CS staff, compromises (contaminated instruments, blood and body fluid spills) are corrected. As patient advocate, the perioperative nurse ensures the critical steps of the pathway are met to prevent a surgical site infection.

Cynthia K. Halvorson, RN, MSN, CNOR, has 24 years of perioperative experience in clinical, educational, and managerial positions in rural, urban, and academic centers of excellence. She has been a generalist staff nurse, clinical specialist, specialty service manager, and a perioperative/outcomes case manger.

For a list of references, access the ICT Web site.

Table 4: Five Rs of Medication Administration to PPA

Right Patient: CDC wound class 1 and 2

Implant or graft placement

Right Route:

Intravenously -- pre-op and intra-operative redosing
Irrigation -- in normal saline for wound irrigation prior to closure
Topical -- otologic and ophthalmic procedures (ointment or drops)
Injection -- subconjunctival for ophthalmic procedures

Right Antibiotic:

Agent per likely SSI pathogen source

Right Time:

30 minutes prior to patient entering OR (one hour if Vancomycin)

Right Dose:

Intraoperatively when agent reaches 1/2 life to maintain serum/tissue effective concentration levels

Adapted from Lewis and Porazzi. Quality Improvement of the Prophylactic Antibiotic Function in Seminars in Perioperative Nursing. Vol. 2 No 2. 210-215.

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