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In the current era of evidence-based medicine, infection control practices and policies are increasingly subject to rigorous scientific study and data. Just as new and promising approaches to infection control issues emerge from the literature, some established practices may be proved unnecessary or irrelevant. Is the operating room (OR) filled with sacred cows, or does the multifaceted nature of OR infection control encourage adherence to long-standing conventions that may be unproven by todays standards? Many questions and unresolved issues linger in the OR.
I think things that get labeled as sacred cows are measures that have grown up over time, and theyre empiric measures, says Rita McCormick, RN, CIC, infection control practitioner at University of Wisconsin Hospital and Clinics. From my perspective, a sacred cow has a negative connotation, whereas an empirical measure suggests that it was given some thought, but not studied in a scientific manner, and its based on what was thought to be common sense, or it just seemed like good practice.
When you talk about the OR, there are many empiricisms that I would be reluctant to tamper with too much without adequate studies. The problem is that typically the outcome people would like to link to a study is a reduction in surgical infection rates. Well, surgical infection rates are so multi-factorial, that even if they did go down, you might not know exactly why.
Home Laundering of Scrubs
This issue has yet to be definitively resolved, according to Marcia R. Patrick, RN, MSN, CIC, infection control director at Tacoma, Wash.- based Multi-Care Health System. There are no large, well-controlled studies on this. Anecdotal reports include an increase in infection rates in some situations, but no effect in others. If healthcare workers are using home-laundered scrubs, they should be covered on a hanger, or in a bag while theyre carried and put on just before starting the shift. Scrubs soiled with blood or body fluids cannot be taken home for laundering, but must be sent to the hospital laundry. This is per the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. ORs allowing home laundering must have a policy and procedure for how to manage contaminated scrubs.
Many facilities that do not allow home laundering have staff members that do it anyway, for a variety of reasons, Patrick notes. An odd size might be needed and is not in good supply, like extra small or extra large, or a common size that is quickly depleted from the shelves, she says. Others cite home laundering as better for their skin; hospital washing makes them break out or get irritated.
Laundering scrubs at home has been implemented by facilities in the past five years, and supposedly weve seen no difference in infection rates. How are they looking at that how rigorous is it? McCormick questions. Most the infection surveillance is done by the infection control group, and to be able to sort out the many different potential contributing factors when looking at surgical site infections as the outcome is extremely difficult. Given the limited resources that are committed to surveillance, they dont have much of a chance of being able to identify whether or not laundering scrubs at home made a difference. It would take a huge study that was very well-funded to get numbers sufficient to make that determination. The cost to do that kind of study would be extremely prohibitive.
When the results of an infection can be so devastating, McCormick questions the decision to cut costs in this area. If everyone in the hospital is wearing scrubs, and thus having them laundered at home made a huge difference in cost, then youd need to look at whos wearing them and why. In the OR arena, where you have sterile surgical procedures, I think they should be laundered in the hospital, because that has been such an issue with costs in terms of people pilfering or misusing them. Most facilities will tell you that once they implemented the machines that dispense scrub suits and they utilized criteria for who can wear them, their costs went down.
With regard to this issue, Patrick points out that the Association of periOperative Registered Nurses (AORN) Standards prohibit them, and the Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Healthcare Settings states, Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (e.g., those in intensive- care units or operating rooms) (IA) (350-353).1 This has been a long-standing policy in ORs, and in many facilities it has been extended to all staff members who have patient contact. Artificial nails hold a much greater number of bacteria and a wider range of organisms, particularly gram-negative rods, than short, well-trimmed nails, she adds.
The data is pretty good on this one, Mc- Cormick says. I feel like theres enough data when you look at bacterial adherence to artificial nails as opposed to natural nails, and when you look at the causal relationship behind certain outbreaks, Im very comfortable with the idea that fake fingernails dont belong in the clinical arena. It got attention through the CDCs hand hygiene guideline, and its pretty well-documented there. In order to get that kind of support from the HICPAC (Healthcare Infection Control Practices Advisory Committee) guidelines, the documentation needs to be rather firm, and it met that criteria.
Operative Site Shaving
This issue has resurfaced, as it is included in the Institute for Healthcare Improvement (IHI)s bundles for prevention of surgical site infections, Patrick comments. It has long been recommended that hair removal, if necessary, be done with clippers immediately before the procedure.2
If youre gong to remove hair hours earlier, then theres good reason to believe that clipping is better than shaving, or not doing anything at all if you dont have to, McCormick says. That could be a ritual that needs to have a little more common sense in place. Does the hair interfere with your ability to suture the wound? If it doesnt, maybe you dont need to do anything; just prep it. It is my understanding that we dont have good comparative data that looked at shaving immediately before incision vs. clipping. Most of the studies cited in the CDC guideline were done in the 70s and 80s, when patients were admitted to the hospital prior to surgery and were shaved the evening before. Micro abrasions of the skin with time for skin flora to multiply were more likely to occur in this type of setting and may have been the reason for these findings. In general, clipping is the preferred method.
Shoe Covers and Cover Gowns
Patrick explains that shoe covers were originally worn to reduce the amount of bacteria on the feet being brought into the OR. Today, they are used to protect the shoes and feet from blood and body fluid spatter, as required by Bloodborne Pathogens Standard, she says. Many, if not most OR staff members have dedicated OR shoes that stay in the locker room when not being worn. Shoe covers now include water-resistant booties and boots to protect the feet and legs during procedures with potential for spraying or splashing.
There is good reason for OR personnel to cover their feet so that when blood is spilled it doesnt soil their shoes, exposing individuals to greater risk, McCormick adds. For some of the really wet procedures, they have even more extensive protective apparel that includes waterproof protection up to the knees. In some of the orthopedic and urology procedures, those people get soaked on the lower legs. Shoe covers have their role primarily as protective apparel.
The use of cover gowns outside OR is in fact a sacred cow, according to Patrick. There is no evidence that they do anything to reduce infection. Some facilities still require them, but many do not. She notes that context is an important consideration in terms of potential contamination. A worker going to a nursing unit to pick up the next patient, who will assist with moving the patient from bed to gurney, and gets up on the bed and kneels on it, or pulls the patient against their scrubs is likely to be more contaminated than someone going to the cafeteria or the lounge.
When I was a student nurse in my OR experience, we could not leave the OR with our scrubs on we had to change into a standard uniform and change again when we got back, McCormick recalls. There again its a cost issue, because you have to pay for change time; it would add five or 10 minutes on to a half-hour lunch period, and time is money. People migrated toward the use of cover gowns so that when they went to the cafeteria or other areas, they didnt pick up more contamination.
Some facilities bought laboratory coats to put on, but then the issue is, are they worn correctly, how frequently do they get laundered, do they really prevent contamination, can we link any infection in a patient to the apparel of the worker? McCormick continues. Probably not; the surgical gowns that they now wear are more likely to be fluid resistant. (Certain) gowns that are frequently worn dont allow migration through the fabric very well. Do we have any scientific evidence? We have a little bit with (certain) gowns. Funding for doing those kinds of studies is unlikely. Once again, maybe the better outcome to measure would be, not if the patient got an infection, but what was found on the gown when they took it off? Was it the workers own endogenous flora on the front of the gown, or flora from the operation? Those are very difficult studies to do.
Hand Hygiene Issues
Preoperative hand scrubbing has evolved from a grueling 10-minute, scrub-brush assisted routine, to one this is potentially quicker and more gentle on clinicians skin. The CDC Guideline for Prevention of Surgical Site Infections recommends a two-minute to five-minute scrub with an appropriate antiseptic, Patrick explains. Since publication of the Guideline, a number of products have come on the market that have shortened the surgical skin preparation time. Some are waterless, some use water. They generally are alcohol-based, with a chemical to aid in persistence added, such as CHG (chlorhexidine gluconate). Some require multiple applications and have specific steps to follow to obtain the desired effect, which is to reduce the amount of microbial flora on the skin and keep it low for the duration of the procedure.
She adds that the alcohol products have been in use for some time in Europe, although they are relatively new to the United States. Studies show that use of a scrub brush actually abrades the skin and causes increased shedding of skin squames. It also may allow adherence of bacteria to the skin that would not occur without the use of the brush. The ideal scrub is one that has fast kill, broad-spectrum kill, and persistence on the skin.
Patrick points out that she often sees a practice gap in ORs involving lack of hand hygiene when in contact with the patient or the patients environment. OR staff members must gel their hands on entering and exiting active ORs, she emphasizes. I see circulators and staff members leaving the room to get equipment, take a specimen out, etc., and go back and forth, touching environmental surfaces like telephones, pneumatic tube systems, and so on, then entering the room and touching counters, phones, and other items. We recently opened a new OR, and have hand gel right outside the door of each room, on the core side. Our motto is, Gel in, gel out. Then it doesnt matter if the patient has methicillin-resistant Staphylococcus aureus (MRSA) that we are not aware of, or any other bug.
Other Hot Topics
I think skin antisepsis is still an issue whats the best product to use on the skin? McCormick points out. Chlorhexidine might be a product that facilitates positive outcomes for the prevention of catheter-related infections with repeat applications, but Im not sure its safe to take that information and generalize it to the surgical patient, where you put it on one time and make the incision. If you look at the major skin antiseptics used on the surgical side prior to incision, its either aqueous povidone iodine, alcoholic tinctures of povidone iodine, or chlorhexidine. They have not been compared head-to-head to the degree that some would like. We need more randomized, clinical, controlled studies that have been done in clean surgeries, not clean-contaminated surgeries, because there are too many other things that figure into the infection rates that people get from contaminated surgeries.
Another controversial issue is the use of preoperative scrubs or showers by the patient the night before or morning of surgery, according to McCormick. She mentions a recent literature review that found no evidence that these showers are beneficial.3 But they didnt elaborate on why there was no evidence; they didnt go into the details of the studies they reviewed the methods used in the studies were flawed or not specified. I think it really does require a more rigorous look at teaching the patients exactly what you expect them to scrub, how long you expect the antiseptic to stay in place, and whether you rinse it off or not. None of these things were addressed in the meta-analysis study by Webster and Osborne. Contact time plays a very significant role in what organisms remain on the skin. Thats a controversial issue that has not yet been measured by a good prospective, randomized trial.
Probably one of the hottest issues is administration of the perioperative antibiotic within one hour of incision, Patrick notes. This is another IHI element, and compliance is also being measured by other groups, including Centers for Medicare & Medicaid Services (CMS). Facilities that consistently meet this standard are those that administer the antibiotic in the OR, often at the time out before the start of the case, when the patient, the procedure, and the side site are verified by the whole operative team. Anesthesia or the circulating RN gives it via IV push. Getting the drug in during that hour before the incision has a significant impact on reduction of surgical site infections.
1. Guideline for Hand Hygiene in Health-Care Settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol. 2002 Dec;23(12 Suppl):S3-40.
2. Mangram AJ, et al. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1999 Apr;27(2):97-132; quiz 133-4; discussion 96.
3. Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD004985. Review.