It was approximately two years ago that I first wrote about the two-step handwashing technique for the operating room (OR). The idea was to wash and/or or scrub one’s hands with hospital-grade soap to clean the hands before starting the surgical scrub with an antimicrobial solution. The idea is much like cleaning surgical instruments before sterilizing them. Now, my thoughts on the matter grow more profound as I watch surgical personnel come to the scrub sink with gross matter on their hands and start a surgical scrub with alcohol-based scrub solutions using a brushless technique. We still don’t get it!
I feel lost in the OR, knowing that multidrug-resistant organisms (MDROs) are everywhere. Studies show pathogens are on equipment, surfaces, walls, patients, staff, stretchers, supplies and hospital beds, yet this subject is one nobody wants to address directly – MDROs in the OR! The Centers for Disease Control and Prevention (CDC) is willing to say that 20 percent to 90 percent of hospital employees may be colonized with Staphylococcus aureus; I have a feeling that OR personnel make up some of the highest percent of those colonized. Other studies suggest colonization with MRSA among healthcare workers (HCWs) in high-risk areas such as ICUs and ORs may be as high as 30 percent. HCWs carry C. diff on their hands and on their uniforms. Once on their uniforms, C. diff will travel around the hospital, leave work with you and go home with you. You will re-inoculate your hands by touching your uniform, even though you washed your hands and used an alcohol-based handrub before you left the hospital.
With the dramatic rise in hospital-acquired infections (HAIs) I hear constantly, “Where are the infections coming from?” The words Dr. William Halsted spoke 100 years ago still ring in my ears: “The operating room is a laboratory, a laboratory of the highest order!” It is time that surgical aseptic technique and OR sanitation rise to a new level.
There are basic, timeless principles of aseptic and surgical techniques, OR sanitation and OR traffic patterns that guide us from the start to the end of a procedure, and those principles are becoming lost as we get sloppy with our technique. I have compiled a list of some time-tested principles of infection control in the OR as they relate to MDRO prevention. The principles of aseptic technique never go out of style and always work in conjunction with new evidence-based practices. These practices drastically improve infection control in the OR and reduce the incidence of surgical site infections and colonization of HCWs and patients. The important issues are saving patients’ lives, preventing poor patient outcomes and lawsuits from wrongful deaths, and saving hospitals millions of dollars a year to care for patients with HAIs.
The following recommendations are based on the principles of not bringing microbes into the OR as well as eradicating any existing microbes in the OR:
1. Stop all unnecessary traffic through and into the OR, including traffic by emergency department and ICU personnel. No shortcuts through the OR should be allowed; HCWs must use the main entrance to their own units.
2. Stop all room-to-room traffic, such as when HCWs look for items not found in their own OR. All unused or unnecessary equipment should not be stored in any OR; instead, keep equipment in designated places outside the OR but close at hand. The OR should look barren upon entering the room. You should see a room that also smells clean and you should almost be able to smell and see the sterility. Nothing should be on the walls because the walls must be cleaned. The floors must no longer be considered “always dirty.” If all of the other parts of the OR were cleaned and disinfected, shoe covers would have a new use — to keep the OR floor clean. Shoe covers should be kept just outside the OR doors or mounted to the wall. Shoe covers should be donned just before entering the clean room for surgical procedures. If an accreditation agency watched each clean-up before and between cases, as well as daily, weekly, monthly and quarterly cleaning and disinfection, most ORs would fail this test. We would also fail if we were tested on our knowledge of how to perform procedures using the three basic isolation precautions: contact, droplet and airborne.
3. Limit the number of personnel in each OR, as this will reduce the bacterial shed and the bioburden in the room. All OR personnel must change their hats, masks, shoe covers and disposable safety glasses after each case because these items are likely to be highly inoculated with the last patient’s pathogens. This is especially important for all scrubbed persons who will be leaning over the next patient’s instruments and over their wounds. All non-scrubbed personnel and anyone opening items within the sterile field should wear long-sleeved jackets to cover exposed skin and use clean disposable gloves. Jackets, scrubs and all other personal protective equipment (PPE) must be changed as soon as possible when visible soiling becomes evident. All head and facial hair must be covered; let’s get rid of hats and don hoods to cover up as much skin as possible.
4. Remove all unnecessary equipment and supplies from the ORs. Consider using supply carts that can be changed daily and cleaned. If more space is needed, consider moving adjacent units to make space for OR storage.
5. Remove all built-in cabinets in ORs and use that space for supply carts and essential equipment. The positive pressure inside ORs directs air and microbes into cabinets that are not 100 percent air-tight. Remove all scrub sinks; have a multiple handwashing station in the semi-restricted area with hospital-approved soap and scrub brushes to wash one’s hands. Don’t forget to scrub out after your case at the washing station.
6. Remove all items from the OR walls to facilitate cleaning with EPA-approved, hospital-grade germicidal agents.
7. Keep OR doors shut at all times, even while transferring patients from stretchers to the OR table. Never open the OR doors until the dressings are on the wound unless you must get supplies pertinent to the procedure.
8. Seal all sub-ceiling fixtures with silicone to prevent the positive pressure air movement through the fixtures such as vents, lights and outlets to prevent dust, dirt and microbes from settling, clumping and then falling back into the OR.
9. All patients coming into the OR from the ICU or who have been in the hospital for more than seven days should be highly suspected as being colonized with MDROs. They should be cared for as if they are infected.
10. All hospital beds coming from any unit with or without a patient must have fresh, clean linens and the mattress must be wiped with a hospital-grade germicide. Special attention should be paid to all high-touch areas such as handrails, siderails and head and foot boards just prior to transfer into the OR; this will reduce bacterial shed during transportation. Linens from the patient’s bed should be removed outside the OR after patient transfer to the OR table. Never remove linens from a patient bed inside on operating room with sterile instruments opened.
11. Patients should also be cleaned from their neck to their toes anterior and posterior with a hospital-grade germicidal soap before transportation to the OR. This should be done three times before surgery, at 12 hours, one hour and just prior to transportation to the OR. This should be part of a pre-operative checklist and signed off by the RN on the unit.
12. As soon as the OR is opened for surgery, all of the extra “hold” items and the case cart must be moved outside the room before the patient enters; items left inside the room will collect pathogenic organisms on the outside wrappers and be returned to the sterile processing department (SPD) where further cross contamination will occur. Wrapped trays should not be considered sterile; many times upon holding these wrappers up to a light, you can find holes in them. These trays should by autoclaved in large strikethrough-proof instrument trays. How many instrument trays have been delivered to the sterile field with holes we cannot see, holes large enough for millions of bacteria to enter? One study suggested 4 out of 14 trays are contaminated the moment they are opened.
13. Biofilms can be found throughout the OR. Biofilms, which have a very high concentration of pathogens, can be found on or under OR furniture and the OR table itself. Biofilms can appear as a dirty-looking slime, or they may be dry. Biofilms are also found on items in the OR when tape has been used and then removed. The adhesive left on OR furniture, surgical tables, walls and floors starts collecting pathogens which may not be able to be disinfected. When a biofilm is discovered it must be eradicated.
14. No personal hats, masks or jackets should be worn in the OR. The OR must have an ample supply of these items because they must be changed between cases or when visibly soiled, or at the end of the work period. This is especially true for scrubbed personnel.
15. OR walls, floors and ceilings must be kept in good repair with no plaster exposed. OR furniture should have bumpers installed to prevent damage to the walls. OR walls, floors and ceilings should be seamless so all surfaces can be cleaned and disinfected.
16. No textiles should be kept inside ORs, including blankets, sheets, pillows or foam padding. Pillows should not be wiped down and reused; they should be placed in the laundry hamper to be terminally disinfected. Try this test: take an OR pillow and squeeze all the air out of it; release it and watch the pillow refill with room air ... where was that pillow last — being used by a MRSA patient? Did it come from the ICU? When was it last terminally cleaned? The pillow could have been used to prop up an infected, draining wound. Pillows in the OR should be made of foam and be disposable. (The list of disposable items in the OR of the future would be many and would include: scrubs, sheets, pillows, arm board covers, EKG electrode cables, blood pressure cuffs, anesthesia headrests, elastic mask straps, patient-warming device hoses, pneumatic anti-thrombus boot hoses, and anything else that comes in contact with the patient or the patient’s body fluids. When an item comes in contact with a patient that is not disposable, that item should be sent to the SPD for terminal cleaning and/or sterilization.)
17. All patients with draining wounds or exposed dressings should have their wounds covered before being transported to the OR. If the wound involves an extremity a plastic bag may be used.
18. Consider using disposable sheets and arm board covers. The cost of the sheets in the long run would be less than that of reusable textiles. If I was having surgery, I would ask to have the OR table covered with sterile sheets before I got onto the table.
19. Disposable blood pressure cuffs, EKG electrode cables and stethoscopes should be issued to every admitted patient and should be wiped off with a hospital-grade disinfectant after each use. No clinician’s personal or reusable cuffs and scopes should be used. Stethoscope ear pieces can be wiped clean before personal use.
20. Gloves, alcohol handrubs and hospital-grade germicidal disinfection wipes should be mounted outside of every OR door, for a quick wipe-down on the high-risk areas of the bed or patient transport device just before entering the room.
21. Air filtration in the OR should be managed and documented in a log book by the OR supervisor. ULPA filtration should be used for all incoming air, fresh or re-circulated, HEPA filtration for all outgoing air. Adjuncts can and should be used, such as carbon filtration for incoming and outgoing air, in-duct UV-C germicidal light, for incoming and outgoing air. Ozone levels should not exceed OSHA recommendations for work places.
22. Partial counters and ozone meters should be used to ensure air quality remains at appropriate levels. Multiple levels should be obtained before, during and after surgery on a monthly basis to insure proper air quality, and especially if laminar air flow systems are used; often filters are not changed and that can actually do more harm than good.
23. Surgical tape in the OR should be for single patient use only, and it should not be kept in a bin in the cabinet with 20 or 30 other rolls of tape, each one now cross-contaminated. In some ORs, tape is reused from patient to patient. I have seen tape used to pick up hair clippings then returned to the shelf only to be used on another fresh surgical wound. What are we doing?! Install a tape dispenser to pick up hair clippings!
24. Are hair clippers a great advance for surgical prep? Yes and no. Clippers are usually not disposable, but the clipper blades are. The clippers are used from patient to patient, and most of the time they are wiped before and after prep; however, I have noticed far too many times they still have gross dirt, body fluids and hair left over from past surgical patients. We then apply a sterile blade which still makes nicks in the skin then biological fallout from the clippers drop onto the freshly nicked skin exactly where the incisions will be. Reusable hair clippers must be terminally cleaned and sterilized for each patient use.
25. After any case where large amounts of body fluids and tissue are on the OR floor, a mop and a few cleaning wipes will only spread pathogens around the room and possibly render the room more biological contaminated over a larger surface area. After a very messy case, disinfectant solution should be sprayed with pump sprayers and a wet/dry vacuum with a HEPA filter exhaust should be used until all the gross and visible body fluid and tissue is removed. Once this has been accomplished, the regular decontamination process may begin.
Joseph M. O’Neill, OPA-C, CSA, is a member of the American College of Surgeons, and served on the educational committee for the National Surgical Assistant Association. He speaks on surgical techniques nationally.