Best Practices in Real Life
By Kathy Dix
The Consequences of Sepsis
Talking about asepsis is all well and good, but we must remember why this technique is so important. The end result of blood or tissue infection sepsis is a dramatic and often fatal result of poor aseptic practices. (See sidebar on page 50.)
Sepsis is defined as a severe illness caused by overwhelming infection of the bloodstream by toxin-producing bacteria. It occurs in two out of every 100 hospital admissions, and is caused by infection that can originate anywhere in the body.1 Common sites of nosocomial sepsis include IV lines, surgical wounds and drains, and ulcers or bedsores. Its diagnosis can be confirmed via blood culture, although there may be a negative result if the patient is on antibiotics.
Sepsis causes blood pressure to fall, which leads to shock, then to abnormal organ function. The earliest indicators of this infection are often a change in mental status and hyperventilation. Other symptoms include fever, hypothermia, chills, warm skin, tachycardia and decreased urine output. White blood cell counts may be low or high and platelet counts low; blood gases may indicate acidosis.
Patients with sepsis often require care in the intensive care unit (ICU), with broad-spectrum intravenous antibiotics. Once the infection is identified, antibiotics may be tailored to the specific causative organism.2
Mortality associated with sepsis can be as high as 60 percent if there are other medical problems involved. Of the three forms of sepsis uncomplicated sepsis, severe sepsis and septic shock severe sepsis carries a mortality of 30 percent to 35 percent, and septic shock carries a mortality of 50 percent.
Several steps are crucial to ensuring proper aseptic technique:3
- Ensure antiseptics are being used properly.
- Ensure that regular in-services are being held and attended.
- Ensure that new staff undergoes orientation; this includes all job roles, including receptionists, medical staff and administrators.
- Ensure that you are acting as a proper role model to other staff members.
Appropriate antiseptics include chlorhexidine and iodophor solutions; chlorhexidine works well for surgical hand scrubs and skin preparation, but may irritate the genital area; iodophors are a better option for this area. Hexachlorophene and iodine solutions are not recommended for surgical hand scrubs or for use on mucous membranes, according to EngenderHealth, an international nonprofit organization.
Sterile areas on a staff member who is gloved and gowned cover the area from the chest to the level of the sterile field. Sleeves are considered sterile from 5 cm above the elbow to the cuff. On the patient, any area below the level of the draped patient is nonsterile.
Here are recommendations for ensuring that the sterile field remains so:
- Allow only sterile items within the sterile field.
- Do not contaminate items when they are opened, dispensed or transferred.
- Do not allow unsterile staff members within the sterile field.
- Do not allow sterile staff members within the unsterile field.
- Any sterile barrier that has been wet, cut or torn is now contaminated.
- When in doubt, throw it out.
According to the Association of periOperative Registered Nurses (AORN), 2 million people acquire iatrogenic infections each year in the United States, and 90,000 people die. That statistic is shocking, especially considering how easy it is to prevent many of these infections. In the July 2003 issue of AORN Journal, the association recommends that surgical site infections be prevented by administering prophylactic antibiotics and by not shaving the surgical site unless it is absolutely necessary to prevent interference with the incision. Not only that, but the association also recommends restricting risky activities such exposure to high personnel traffic and reminding other healthcare workers to wash their hands.
Considering the number of infections that occur in hospitals, raising the bar to reduce infection risks should be a top patient safety priority. Each clinician is responsible for ensuring best practice related to infection control, the association recommends. Perioperative nurses must remain vigilant about handwashing, scrubbing and gloving, and ensure that these processes are performed according to standards.
There are several misconceptions about aseptic technique specifically associated with the emergency department (ED) in many hospitals. One of these misconceptions is that all lines or procedures done in the ED are dirty and must be replaced, says Frank McGeorge, MD, an emergency physician and residency program director at William Beaumont Hospital in Royal Oak, Mich.
One needs to take the circumstances of its placement into account, he states. Less emergently performed procedures are done with the same care to aseptic techniques that we employ through the entire hospital. In true emergencies, though, we always have to balance the critical nature of the patients condition with the time needed to perform all steps in a truly aseptic fashion.
There is a second myth associated with the ED that the ED itself is dirtier than the rest of the hospital. Nurses and ancillary staff regularly clean rooms themselves during busier times, in addition to the constant cleaning provided by housekeeping and environmental services, McGeorge says. Because of our rapid pace we are constantly cleaning, and as a result, the ED should be as clean as the rest of the hospital. The only variance to this is related to the unexpected nature of emergencies. That is, we often have unexpected contamination of an area which can occur in an uncontrolled fashion such as when a patient suddenly vomits blood or has diarrhea in their stretcher. In those cases, as soon as the patient is stable, we begin the cleanup.
It is also untrue that emergency personnel just dont pay as much attention to aseptic technique, McGeorge maintains. This misconception is unjustified for two reasons, he explains. First, hospitals and emergency personnel recognize that reducing nosocomial infections begins at the front door, which is what we represent. Policies and procedures for proper identification, triage and isolation of potentially communicable diseases exist in all hospitals. We also know that in the case of blood culture sampling or line placement, our attention to proper aseptic technique has a farreaching impact on the patients entire hospital course.
Secondly, because of our position at the front line, our exposure level to the unknown is higher and extra attention to aseptic techniques is also in our best interest as providers. The bottom line is, aseptic techniques are well known to all ED personnel and we consistently employ them, unless the risk to the patient of a delay in care due to aseptic technique (such as with a cardiac arrest or major trauma) outweighs the time necessary to fully comply with them. If it came down to having a lifesaving procedure performed immediately in a clean way vs. waiting to have it done in a sterile way, most physicians agree the immediacy outweighs the benefit gained by sterility. It is better to be alive with a treatable infection than dead because of a delay in care. We are most interested in doing whats right for the patient, and over 95 percent of the time, careful attention to aseptic technique is part of the answer. In the small minority, the emergent nature of the problem necessitates attention to the patient before full attention to aseptic procedure, he clarifies.
The first misconception often leads to other departments changing a line as soon as the patient is moved out of the ED. There are some who believe very strongly that any line placed in the ED should be considered contaminated until proven otherwise, or by default, says McGeorge. Emergency medicine has come a long way, especially in larger centers, but I think even in smaller hospitals, to isolate patients that have potentially communicable diseases because of all of the threats, terror warnings, and all the miscellaneous health concerns that have come to light over the last several years we do go out of our way to isolate anybody who may be potentially biohazardous to patients around them. Theres certainly an increased awareness of blood, body fluid and respiratory contamination, so the ED policy has been set to specifically address those issues.
The one possible exception to the idea that the ED is not dirtier is in some departments that see a disproportionate number of indigent patients who may have more highly-communicable diseases that would not necessarily be common in a less underprivileged population, McGeorge concedes.
Under those circumstances, while I wouldnt consider the ED to be dirtier, one would need to pay more attention to proper isolation techniques and proper aseptic technique to prevent cross contamination, he says.
The idea that the ED is a dirtier place is often portrayed by popular television as well. Its popularized by shows like ER, where they do have some semblance of universal precautions, but they do also show many scenes where blood and or body fluids are flying around in an uncontrolled fashion, and while thats not necessarily an unrealistic portrayal, what they dont show is the follow-through. We then decontaminate the area, we wash hands very aggressively or change our clothes. So while they show the contamination occurring, they dont show the cleanup occurring, because the cleanups not cool, McGeorge adds. There are time-sensitive issues that may prevent us from doing everything perfectly, but we certainly are aware of the issues, and we do whatever we can within the range of not only safety to other patients but safety to ourselves.
Regardless of the focus on proper technique, McGeorge points out that nobody is perfect. The formation and follow-through of bad habits are human nature, and while we all may have been inserviced on the right thing to do, nobody is perfect all the time. Were all human, and we all do what we need to in the patients best interest, weighing the risks and benefits at hand. However, he says, it is possible to uphold proper aseptic technique, if the facility is willing to take the time to prepare. In real estate, the motto is location, location, location, but in healthcare, its preparation, preparation, preparation.
I think one of the most important elements to the use of aseptic technique within an ED or throughout the hospital is easy access and ready availability of supplies, observes McGeorge. Have handwash at the bedside, or have available either sterile or clean gloves at every bedside, masks, easy access to sterile or protective gowns. Those are all things we do better in the ED than anyplace else in the hospital, largely because we expect those types of second-by-second, minute-by-minute needs more than inpatients do. For us, [supplies are] all at the bedside, in the bedside drawers, or theyre all in the resuscitation room where were working. So for us, its far easier to access this equipment often than it would be for inpatient units. That said, we have more emergencies than they do, so our need for that relative difference is higher. On the other hand, they do more elective procedures, where they have the luxury of time to gather all the equipment in a well-orchestrated fashion. Thats one of the things that sets the ED as a resource apart from other places. You always know where you can grab a pair of sterile gloves, where you can grab the gloves, within seconds.
Preparation in the ED is ongoing; patient rooms and other areas are restocked at least once at the beginning of every shift, and resuscitation areas are restocked immediately after resuscitation. In the case of an endotracheal tube, or a thoracotomy tray, or a chest tube tray, those things would need to be restocked almost immediately because we dont keep an infinite supply of them on hand. If theyre used, they would need to be replaced. There are two good reasons this has to happen. One, first and foremost for the patients safety, but truthfully, all of us in healthcare have a vested interest in making sure that equipment is at the bedside because we are being exposed as well, so its just as much in our interest as it is in the patients interest, he says.
Ensuring this flow means planning ahead, even as early as when the department is designed, placing sinks in multiple easily-accessible locations, ideally in every room if possible, so you can wash your hands; the easy availability of waterless handwashing solution, the easy availability of protective equipment, making sure that patients are properly triaged into areas that are relatively either clean or dirty. If you have an area dedicated to suturing lacerations, you would not want to take patients with abscesses and put them in those rooms. You would ideally put patients with infected wounds in different rooms, so the risk of infecting otherwise clean rooms would be reduced.
Ultimately, McGeorge says, Its attention to the detail of the chief compliant and attention to the patient. If a patient has obviously weeping oozing sores and their chief complaint is infection and fever, you wouldnt want to place that patient in an area where they could easily be exposed to other uninfected wounds. Aggressive environmental service detailing and/or housekeeping maintenance is very important.
At McGeorges hospital, the basic recommendations for environmental services are followed, but this is not to say that only the environmental services team is involved in cleaning. When McGeorge utilizes one room with a special ophthalmologic lamp, First, the area is cleaned after the patient has used it; the area is cleaned before a new patient uses it. When I see a patient, I assume that the person before may not have cleaned it off, so I clean it off using an alcohol swab, and I put a protective barrier on it, either a piece of tissue paper or some other protective barrier to add another layer. When Im done using it, I wipe it down again.
McGeorge continues, There are checks and balances, because you make assumptions that nobodys perfect, human nature being what it is, and so you do have to have some built-in redundancy to cleaning techniques, especially in what would be an obviously chaotic and/or disruptive or noncontiguous environment. Its not always the same people working in the same area all the time. I may be seeing a patient in the eye room, and it may be one of my partners six hours later using that room, and we dont know what the other person has done with it, which is very different from a doctors office, or an inpatient unit, where its the same providers using the same equipment over and over again.
He concludes, I think the most important question to ask is, If this were me, would I want to lay on that surface? Would I want to put my chin there? Would I want this object touching my body? If the answer to that is no, then clean it! You should do what youd want for yourself and your family. It really is the golden rule. The golden rule gets followed as much as you can, to the limit of human nature and the time-sensitive nature of saving someones life.